Limud Application

Please fill out the below form and submit.  If you would rather print out a form and bring it in, click
HERE for form.


 

 


 

Student
Information
Student’s Name: Nickname:
Grade: School: Sex: 
Hebrew Name: Date Of Birth:
Address:
City, State, Zip: (5 digits)
Home Phone: Student Email:
Parent/Guardian 1
Name: Email:
Bus. Phone: Cell Phone:
Parent/Guardian 2
Name: Email:
Bus. Phone: Cell Phone:
Parent/Guardian 3
Name: Email:
Bus. Phone: Cell Phone:
Child Lives with: Parent 1:
Parent 2:
Parent 3:
Other
Living Situation:
Emergency Contact Information
In case of an emergency AND we are
unable to reach any parent/guardian we may contact:
Name: Phone #
Relationship to Child
In
case of a TRUE medical emergency, please contact:
Physician’s Name: Phone Number:
Dentist’s Name: Phone Number:
Medical Information
Does
your child have any health issues of which we need to be aware?  Yes No
If yes, please describe:
Does
your child have any medication of which we need to be aware?  Yes No
if yes, please list:
Does
your child have any allergies of which we need to be aware?  Yes No
if yes, please list:
General Learning Profile
Does
your child have any learning issues that we need to address in the
Religious School?  Yes No
if yes, please describe: 
Does
your child receive any special education services at their
public/private school?  Yes No
if yes, please provide us the name of the service provider or contact
person, as soon as possible, so that we may discuss your child’s
learning strategry.  Please inform this person that we have your
permission to discuss your child’s needs.  Also if yes, please
describe the services your child receives:
Is
there anything else you would like us to know about your child
(subjects the he/she particularly likes or dislikes, special interests
or hobbies, areas of strength or weakness, significant changes in
school or at home that your child has experienced in the past year,
etc.)?
Authorization
In case of
medical or surgical emergency, I hereby give permission to the
physician selected by a representative of Merkaz Ha-Iyr, to
hospitalize, secure treatment for, and to order injection, anesthesia
or surgery for the applicant named.  All attempts will be made to
contact parent beforehand.I certify that my child listed above is physically able to participate
in all activities that are in conjunction with Congregation Merkaz
Ha-Iyr for the period commencing August 2015 through May
2016.  I hereby release Congregation Merkaz Ha-Iyr and allied
organizations, their agents and employees from any and all liabilities
of any nature whatsoever that may arise from his/her participation in
any school related activity.
Please
fill in your name and today’s date to electronically accept the above
authorization:

NAME: 
DATE:

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