EMEK HEBREW ACADEMY TEICHMAN FAMILY TORAH CENTER

15365 Magnolia Blvd, Sherman Oaks CA 91403 www.emek.org

APPLICATION FOR ADMISSION FOR NEW STUDENTS 2011

NAME OF APPLICANT BIRTHDATE HEBREW NAME GRADE ENTERING
 Male Female / /

APPLICANT ADOPTED  YES  NO U.S. VISA # DATE OF ARRIVAL TO U.S.A. (if applicable)

FATHER OR GUARDIAN’S INFORMATION

 MR. DR. RABBI FIRST NAME LAST NAME HEBREW NAME

 Cohen  Levi  Yisroel  Convert  ( If converted to Judaism, please submit documentation)

HOME ADDRESS CITY STATE ZIP

HOME TELEPHONE HOME FAX CELL PHONE HOME E-MAIL

WORK ADDRESS CITY STATE ZIP

WORK TELEPHONE WORK FAX WORK E-EMAIL OCCUPATION & TITLE

PLEASE CHECK ONE: BUSINESS NAME TYPE OF BUSINESS

 SELF EMPLOYED  EMPLOYED

MOTHER’S OR GUARDIAN’S INFORMATION

 MS. MRS. DR. FIRST NAME LAST NAME HEBREW NAME

 Cohen  Levi  Yisroel  Convert  ( If converted to Judaism, please submit documentation)

HOME ADDRESS CITY STATE ZIP

HOME TELEPHONE HOME FAX CELL PHONE HOME E-MAIL

WORK ADDRESS CITY STATE ZIP

WORK TELEPHONE WORK FAX WORK E-EMAIL OCCUPATION & TITLE

PLEASE CHECK ONE: BUSINESS NAME TYPE OF BUSINESS

 SELF EMPLOYED  EMPLOYED

CHILD/CHILDREN LIVE WITH: Both Parents  Father  Mother  Other 

MARITAL STATUS: Married  Remarried  Separated  Divorced  Widowed 

*In the case of separation, divorce, or adoption, it is necessary for the school to have this information and signatures of both parents.
Please submit this information on a separate sheet, if necessary. If not available, please provide an explanation.
Also, if available, kindly submit any official court agreements. Please check if documents are included. 
 PLEASE LIST ALL SCHOOLS ATTENDED STARTING WITH PRESCHOOL
SCHOOL CITY & STATE DATES OF ATTENDANCE

 Has the applicant undergone any visual, hearing, speech or educational assessment? Yes  No 
 Does the applicant have any specific academic or emotional needs that have been identified? Yes  No 
 Is your child currently taking a prescription medication? Yes  No 
(Please supply documentation and information to any of the YES answers to the above questions)

MATERNAL GRANDPARENTS INFORMATION

FIRST / FAMILY NAME

HOME ADDRESS CITY STATE ZIP

PHONE NUMBER E-MAIL

PATERNAL GRANDPARENTS INFORMATION

FIRST / FAMILY NAME

HOME ADDRESS CITY STATE ZIP

PHONE NUMBER E-MAIL

CONGREGATION WITH WHICH FAMILY IS AFFILIATED:

NAME OF RABBI / SHUL:

DATE: SIGNATURE OF PARENT OR GUARDIAN:

DATE: SIGNATURE OF PARENT OR GUARDIAN:

REGISTRATION FEE, P.T.A. & TESTING CHECK MUST BE ATTACHED TO REGISTRATION FORM

NURSERY AND PRE-1ST THROUGH 8TH GRADE-REGISTRATION FEES PER CHILD  CHECK THIS BOX IF YOU
$ 450.00 Non-refundable registration fee per child. ARE APPLYING FOR
$ 50.00 1st – 8th grade evaluation fee (both Judaic and General Studies). FINANCIAL ASSITANCE.
$ 95.00 P.T.A. (payable to Emek P.T.A.) dated 9-1-2011 PLEASE INCLUDE
SCHOLARSHIP
OFFICE USE ONLY TESTING FEE JUDAIC RECORDS GENERAL RECORDS NOTES:
PROCESSING FEE OF $45.00

Emek maintains a non-discriminatory policy for all students of the Jewish faith, without regard to race, color, national or ethnic origin.
Revised Jan, 2011