Application for Registration K-12

Please complete the form below. Required fields marked with an asterisk *

Student's Last Name*

Answer Required

Student's First name*

Answer Required

Student's Legal Name*

Answer Required

Student's Hebrew Name

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal

Answer Required

Mobile Phone*

Number Required

Social Security #

Answer Required

Student's Date of Birth*

Answer Required

Date Entered U.S.A.

Answer Required

PREVIOUS EDUCATION:

NAME OF SCHOOL - GRADE - CITY

Answer Required

NAME OF SCHOOL - GRADE - CITY

Answer Required

Has your child ever attended Be'er Hagolah?

Answer Required

If Yes, which year? What Grade?

Answer Required

LIST THE NAMES OF ALL MEMBERS IN THE HOUSEHOLD (ADULTS&CHILDREN):

Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Grade

Answer Required

Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Grade

Answer Required

Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Grade

Answer Required

Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Grade

Answer Required

Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Grade

Answer Required

Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Grade

Answer Required

Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Grade

Answer Required

UPLOAD STUDENT'S PHOTOGRAPH HERE

Answer Required

Choose a file or drag it here.

THIS FORM MUST BE COMPLETED FOR SCHOLARSHIP.

ALL INFORMATION PROVIDED WILL BE CONSIDERED CONFIDENTIAL.

FATHER

Are you employed?

Answer Required

Yes

Employer

Answer Required

Work #

Number Required

Position

Answer Required

How long

Answer Required

Monthly gross income

Answer Required

Other income

Answer Required

MOTHER

Are you employed

Answer Required

Yes

Employer

Answer Required

Work #

Number Required

Position

Answer Required

How long

Answer Required

Monthly gross income

Answer Required

Other income

Answer Required

Do you receive any assistance?

Answer Required

Welfare

Food stamps

SSI

Pension

Child support

Would you be interested in applying for vouchers

Answer Required

Yes

Do you rent or own your apartment?

Answer Required

Rent

Own

How much is your monthly rent or mortgage

Answer Required

Do you own your car

Answer Required

Yes

If YES, what is the make and year?

Answer Required

Additional Notes:

Answer Required

Parent's Signature

Answer Required

Registrar's Signature

Answer Required

Date:

Answer Required

PARENTS' INFORMATION

FATHER'S

First Name*

Answer Required

Last Name*

Answer Required

Hebrew Name

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal

Answer Required

CELL PHONE #*

Number Required

E-Mail

Answer Required

Date of Birth*

Answer Required

Place of Birth*

Answer Required

Date Entered U.S.A.

Answer Required

From which country*

Answer Required

Do you have an Israeli citizenship*

Answer Required

Yes

MOTHER'S

First Name*

Answer Required

Last Name*

Answer Required

Hebrew Name

Answer Required

Mother's maiden name (before marriage)*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal

Answer Required

CELL PHONE #*

Number Required

E-MAIL

Answer Required

Home Phone #

Number Required

Date of birth*

Answer Required

Place of birth

Answer Required

Date entered U.S.A.

Answer Required

From which country*

Answer Required

Do you have an Israeli citizenship*

Answer Required

Yes

PARENT'S SYNAGOGUE

Answer Required

Family's Rabbi

Answer Required

Rabbi's Phone #

Number Required

Marital Status

Answer Required

Married

Divorced

Widowed

Separated

If parents are separated or divorced, who is the legal guardian

Answer Required

Mother

Father

Father remarried

Answer Required

Yes

Mother remarried

Answer Required

Yes

Any relevant documents pertaining or responsibility for school tuition should be made available to the school

Paternal grandparents (Father's Parents):

Answer Required

Place of residence

Answer Required

Maternal grandparents (Mother's Parents):

Answer Required

Place of residence

Answer Required

GENERAL INFORMATION

HOW DID YOU HEAR ABOUT BE'ER HAGOLAH?

Answer Required

WHAT WOULD YOU LIKE YOUR CHILD TO GAIN AT BE'ER HAGOLAH INSTITUTES?

Answer Required

WHAT SUBJECTS DOES YOUR CHILD ENJOY MOST?

Answer Required

WHAT ARE SOME HOBBIES YOUR CHILD ENJOYS MOST?

Answer Required

Please fix the highlighted areas below before submitting.

Application for Registration K-12