Alef Academy Online Registration Form
Child Information
First and Last Name
*
First Name
Last Name
Name Child is called:
Date of Birth
*
Gender:
Male
Female
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
-
Area Code
Phone Number
Parent Information:
Parent #1 Name:
*
First Name
Last Name
Relationship to child:
Jewish
*
Yes
No
Other
Email:
*
example@example.com
Cell Phone:
*
-
Area Code
Phone Number
Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation:
Employer:
Work Phone:
-
Area Code
Phone Number
Employer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent #2 Name:
First Name
Last Name
Relationship to child:
Jewish
Yes
No
Email:
example@example.com
Cell Phone:
-
Area Code
Phone Number
Address: (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation:
Employer:
Work Phone:
-
Area Code
Phone Number
Employer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
During the hours that my child is at Alef Academy, the best way to reach me is:
*
Family Information
Family Synagogue Affiliation:
Marital Status of Parents:
Languages spoken at home other than English:
Are there any conversions in the family?
*
Yes
No
Other
If yes, please specify who.
Previous Day Care or Schooling Experience
School/Day Care Center
Attended from
blanks
to
blank
.
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Emergency Contact/Authorized Pick Up Information
Licensing requires that we have 3 emergency contacts on file. Please include name, relationships, address, and phone number.
Contact #1
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
Relationship
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
This contact is also authorized to pick up my child from school.
*
Yes
No
Contact #2
*
First Name
Last Name
*
Relationship
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
This contact is also authorized to pick up my child from school.
*
Yes
No
Contact #3
*
First Name
Last Name
*
Relationship
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
This contact is also authorized to pick up my child from school.
*
Yes
No
Signature of Parent or Guardian
*
Date:
*
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Grandparent Information
Optional so we may include grandparents in school special events.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Maternal
Paternal
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Maternal
Paternal
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Maternal
Paternal
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Maternal
Paternal
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Medical and Emergency Form
Doctor's Name
*
First Name
Last Name
Name of Practice
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
In case of an emergency, my preferred hospital is:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Does your child have medical insurance?
*
Yes
No
Insurance Provider
*
Insurance Policy Account #
Dentist's Name
*
First Name
Last Name
Name of Practice
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Medical Condition(s)
*
Yes
No
Is your child taking any medication at home?
*
Yes
No
If yes, please specify.
Does your child have any known allergies? (food, season, insects, etc.)
*
Yes
No
If yes, please specify reaction and treatment.
Is there anything special we should know about your child?
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Statement of Authorization
Emergency Medical Treatment - I hereby give my consent to Alef Academy to call a doctor or emergency medical service and for that doctor or emergency service to provide emergency medical or surgical treatment to my child.
Yes
No
Sun Screen - I hereby give my permission for staff to apply Sunscreen to my child prior to outside play.
Yes
No
It is the parent’s responsibility to provide sunscreen with a minimum SPF of 15. In the event that my child’s sunscreen is not readily available
My child may use the sunscreen provided by the school:
I do not want my child to use any other sunscreen other than the one he or she brings.
Name of sunscreen and the SPF Number:
Initials
I hereby give permission to The Alef Academy to post my child's allergy information in the visible area of classrooms so that it is accessible to all staff.
Yes
No
Other
I hereby give permission to The Alef Academy to print our address and phone number on the class list, which will be distributed to my child's class and in the school phone directory which will be distributed to all Alef Academy families.
Yes
No
Other
Photo Release - I hereby grant my permission for my child's photo to be taken and displayed in classrooms, hallways, or stored in a file.
Yes
No
Other
Media Release - I hereby grant my permission for my child's photo to be taken and used in newsletters, flyers, and/or for any other advertisement purposes.
Yes
No
Other
Cot Permission - I herebygive my consent for my child to sleep on a cot during naptime. (18 months or older)
Yes
No
Other
I understand that tuition is due a month in advance:
Yes
No
Other
I understand that if it becomes necessary to withdraw or change my child's schedule, notice must be given in writing one month in advance. Tuition will be charged for one month after the date of notification of the withdrawal or change.
Yes
No
Other
I have read the Parent Handbook. I understand all of the policies and procedures and agree to abide by them.
Yes
No
Other
Signature
*
Date:
*
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Tuiton Information
I would like to register my child for the following days and times:
2 Day HALF DAY
2 Day FULL DAY
3 Day HALF DAY
3 Day FULL DAY
5 Day HALF DAY
5 Day FULL DAY
I would like Before Care 8-9
Yes
No
I would like Before Care 8-9
2 Day: Tuesday & Thursday
3 Day: Mon, Wed, Fri
5 Day: Mon - Fri
I would like After Care 3-5
Yes
No
I would like After Care 3-5
2 Day: Tuesday & Thursday
3 Day: Mon, Wed, Fri
5 Day: Mon - Fri
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