KESHER
Registration Form
Date ____________
Name of Student: ____________________________________Birth date: __________
(Last) (First)
(Hebrew)
Month/Day/Year
Male [ ]
Female [ ] Home Phone: ________________
**Time of Birth______
Address:
__________________________________________________________
Parents’ Names: Mother
_____________________________
Father
_____________________________
Child lives with: [ ]
Both Parents [ ] Mother
[ ] Father
Marital Status of
Parents:
[ ] Married
[ ] Divorced [ ]
Separated [ ] Widowed
If divorced or
separated, address and phone of parent with whom child does not
reside:
Address:
__________________________________________________
Phone: ____________________
Where can parents be
reached if not at home?
Mother: Address
___________________________________________
Phone: ____________________
Father: Address
___________________________________________
Phone: ____________________
Name of
Public/Private School: ________________ Present Grade:__________
Special Interests
& Hobbies:__________________________________________
Emergency Contact
(to be called in case of emergency when parents cannot be reached):
Name:
______________________________ Phone Number:________________
Additional Numbers,
if applicable:
Cell Phone:
____________________ Fax: ______________________
List two neighbors
or nearby relatives who will assume temporary care of your child if you cannot
be reached:
1. _________________________________________________________________
Name Address
Phone
2.
_________________________________________________________________
Name Address
Phone
In case of accident
or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby
authorize the school to call the physician indicated below and to follow
his/her instructions. If it is
impossible to contact this physician, the school may make whatever arrangements
seem necessary.
Signature of parent or guardian:
___________________________________________
Allergies or other
health conditions which the school should be aware of:
_____________________________
Pertinent educational
information which would be helpful in instructing your child, i.e.: learning
disability, gifted, visual, auditory, speech problems, etc. If additional space is required, use other
side.
Local Physician’s
Name: ____________________
Address:
______________________
Phone: ___________
** (We want to
establish the Hebrew birth date for your child, if we have not done so
already.)