Homeschool Coop Registration

Child's Name*

First NameLast Name

Hebrew Name*

Date of Birth*

MonthDayYear

Gender

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone*

Area CodePhone Number

Mother's Cell Phone*

Area CodePhone Number

Father's Cell Phone*

Area CodePhone Number

Primary E-mail Contact

Name*

First NameLast Name

Hebrew Name

Jewish by:*

BirthChoice

Occupation

Name of Business

Business Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Business Phone*

Area CodePhone Number

E-mail

Name*

First NameLast Name

Hebrew Name

Jewish by:*

BirthChoice

Occupation

Name of Business

Business Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Business Phone*

Area CodePhone Number

E-mail

What is your child's nickname

Was your child's birth premature*

YesNo

Were there any problems with infancy, physical development, etc.?*

YesNo

If yes, please explain

Has your child ever been hospitalized or had a serious illness?*

YesNo

If yes, please explain

Does your child take any medication regularly*

YesNo

If yes, please explain

Does your child have any allergies*

YesNo

If yes, please explain

Does your child have any food restrictions?*

YesNo

If yes, please explain

Does your child nap?*

YesNo

What time does your child go to sleep for the night and wake up in the morning?

Is your child fully toilet trained?*

YesNo

Does he/she need a reminder to go to the bathroom? Please explain

Does your child dress himself/herself at home?

YesNo

What is the primary language spoken at home?

What other language is your child exposed to?

Does your child speak in

WordsSentences

How does your child show his/her feelings?

What makes your child angry or upset?

Is your child frightened by

Please specify

What do you find is the best way of handling your child when he/she is upset?

What particular play activities does your child enjoy and have a special interest in?

What particular activity does your child NOT enjoy?

Does your child have any physcial or emotional conditions that the staff should be aware of?

Is your child currently receiving therapy or services ?

Does your child live with both parents?*

YesNo

Explain if necessary

Do you have talents, hobbies, etc., that you would be willing to share with or demonstrate for the children in Homeschool Coop?

Grandparents Names

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Grandparents Names

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Is your child adopted?*

YesNo

Has anyone in the immediate family been adopted or converted?*

YesNo

If yes, please explain

Congregation of family's affiliation (if applicable)

I give permission for my child's picture to be used for display and public relations purposes. Please type your name and date.

Picture Permission*

First NameLast Name

Date*

MonthDayYear

Full day- 8am-5:30pm

MondayTuesdayWednesday

Part -time

MondayTuesdayWednesdayThursday

If your child is attending part time, please specify the hours

I agree to the tuition policy. Please initial your name below.

Tuition policy

Homeschool Coop Registration

Child's Information

Mother's Information

Father's Information

About your child

Picture Permission

Day Options

Tuition policy

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