Nursery Student Application

*If you are applying for more than one student, one of whom is going into nursery, please use the New Student Application.
*If you are applying for only one child who will be entering nursery, please use this form.
*Applicants must be 3 years old by October 31st.
*Nursery applications due by February 22.

Email*

Child Information

Child's first name*

Child's last name*

Please call my child*

DOB (English)*

MM slash DD slash YYYY

DOB (Hebrew)*

Child's Hebrew Name

Please type names in Hebrew. If you don't have Hebrew, please spell out the Hebrew letters in English. Ex: Shira = shin yud reish hey

Child's Full Hebrew First Name*

Child's Hebrew First Name - the way you would like your child to recognize his/her name (ex: Full name is אסתר, but you want your child to recognize her name as אסתי).*

Child's Hebrew Last Name*

Is there any particular insight or information about your child that would be helpful for the school to be aware of in order to best educate your child?

Does your child currently attend playgroup?*

Yes

Teacher's Name*

Teacher's Phone Number*

Has your child received any of the following services, either privately or in school, within the past 2 years? Check all that apply. **Application for student receiving any of these services will not be reviewed without the submission of pertinent documents (i.e. evaluations, IEPs, Birth-3 documents)***

Speech Therapy

Language Therapy

Occupational Therapy

Physical Therapy

Psychological Services

Special Education Intervention

My child has not received any of the above mentioned services within the past 2 years.

Medication

Please indicate if your child takes any medication on a daily basis.*

Yes

Please list your child's daily medication*

Please explain*

Do you have other children already registered in Yeshiva K'tana of Waterbury?*

Yes

Family Information

Last Name*

Father's Title*

Father's First Name*

Mother's Title*

Mother's First Name*

Marital Status*

Married

Separated

Divorced

Widowed

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number*

Father's Email*

Father's Cell*

Mother's Email*

Mother's Cell*

Father's Occupation*

Father's Employer*

Business Phone Number*

Business Address*

Mother's Occupation*

Mother's Employer*

Business Phone Number*

Business Address*

Paternal Grandparent Information (1 of 5)

Paternal Grandparents' Last Name*

Paternal Grandparents' Street Address*

Paternal Grandparents' City, State*

Paternal Grandparents' Zip Code*

Home Phone*

Paternal Grandparent Information (2 of 5)

Paternal Grandfather Deceased

Yes

Clear selection

Paternal Grandparent Information (3 of 5)

Paternal Grandfather Title*

Paternal Grandfather First Name*

Paternal Grandfather's Email Address*

Paternal Grandfather's Cell Phone Number*

Paternal Grandparent Information (4 of 5)

Paternal Grandmother Deceased

Yes

Clear selection

Paternal Grandparent Information (5 of 5)

Paternal Grandmother Title*

Paternal Grandmother First Name*

Paternal Grandmother's Email Address*

Paternal Grandmother's Cell Phone Number*

Maternal Grandparents Information (1 of 5)

Maternal Grandparents' Last Name*

Maternal Grandparents' Street Address*

Maternal Grandparents' City, State*

Maternal Grandparents' Zip Code*

Maternal Grandparents' Home Phone*

Maternal Grandparents Information (2 of 5)

Maternal Grandfather Deceased?

Yes

Clear selection

Maternal Grandparents Information (3 of 5)

Maternal Grandfather's Title*

Maternal Grandfather's First Name*

Maternal Grandfather's Email Address*

Maternal Grandfather's Cell Phone Number*

Maternal Grandparents Information (4 of 5)

Maternal Grandmother Deceased?

Yes

Clear selection

Maternal Grandparents Information (5 of 5)

Maternal Grandmother's Title*

Maternal Grandmother's First Name*

Grandmother's Email Address*

Grandmother's Cell Phone Number*

Additional Information

If you wish to include any additional information to your application, please do so below.

Name

This field is for validation purposes and should be left unchanged.