SHEARIM TORAH HIGH SCHOOL FOR GIRLS
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Shearim High School Student Application Form
Student's Information
*
Indicates required field
Name
*
First
Last
Hebrew Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
*
Student Cell Phone Number
*
Email
*
Date of Birth
*
Is student Jewish from birth?
*
Yes
No
Is student a US citizen?
*
Yes
No
Is student adopted?
*
Yes
No
Parents' Marital Status
*
Married
Separated
Divorced
Widowed
Student lives with (check all that apply)
*
Biological Mother
Biological Father
Stepmother
Stepfather
Other
Father's Information
Name
*
First
Last
Is Father Living?
*
Yes
No
Hebrew Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Occupation
*
Employer
*
Work Phone Number
*
If Remarried, Name of Spouse
*
First
Last
Spouse Cell Phone Number
*
Mother's Information
Name
*
First
Last
Is Mother Living?
*
Yes
No
Hebrew Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Occupation
*
Employer
*
Work Phone Number
*
If Remarried, Name of Spouse
*
First
Last
Spouse's Phone Number
*
Family Information
Please list any other children and their ages
*
Synagogue Affiliated With
*
Academic Information
Previous Schools Attended and Dates of Attendance
*
Has student had any educational testing?
*
Yes
No
If yes, provide date of testing and if student has IEP
*
Has student had psychological testing or counseling?
*
Yes
No
If yes, provide date of testing or counseling
*
Medical Information
Please specify any current medical conditions student has
*
Please specify any medications student is taking, and what medical condition it is prescribed for
*
Please specify any allergies student has
*
Emergency Contacts
Contact #1
*
First
Last
Relationship to Student
*
Cell Phone Number
*
Home Phone Number
*
Work Phone Number
*
Contact #2
*
First
Last
Relationship to Student
*
Cell Phone Number
*
Home Phone Number
*
Work Phone Number
*
I hereby affirm that all information contained in this application is truthful and accurate.
*
(Affirm by checking the box to the left)
Submit