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Part One: Student Profile
Choose Your Option
Last Name
First Name
Hebrew Name
Age
DOB
School
Grade Entering

Part Two: Religious & Educational History
Previous Hebrew Education
Hebrew Reading Proficiency None Somewhat Well
Any difficulties in general studies Yes No
Where there any conversions and/or adoptions in the family? Yes No
If Yes, Please explain

Part Three: Parent Information
Address
City/Zip
Phone
Father's Name
Father's Occupation
Father's Cell
Father's Email
Mother's Name
Mother's Occupation
Mother's Cell
Mother's Email

Part Four: Emergency Information
Emergency Contact 1
Phone

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.



Part Five: Referrals
How did you hear about the Jewish Community Center Hebrew School?
Comments/Questions
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