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Grade 9 Application Form

    Applicant Information


    Legal Given Name(s) as on Birth Certificate

    Legal Last Name

    Date of Birth (format dd/mm/yyyy)

    Place of Birth

    Date Moved to Ontario if Born Out-of-Province

    Citizenship/Immigration Status

    Applicant's Cell Phone

    Applicants E-mail Address

    Parent Information

    Marital Status (please check all that apply):
    MarriedSeparatedRemarriedDivorcedWidowed

    If parents are divorced/ seperated, custody has been awarded to:

    father, mother, joint etc


    Father’s Title

    Father’s First Name

    Father’s Last Name

    Home Address Suite#

    City

    Postal Code

    Home Telephone (format xxx-xxx-xxxx)

    Father’s Occupation

    Work Address

    Work Telephone (format xxx-xxx-xxxx)

    Cell Phone (format xxx-xxx-xxxx)

    E-mail

    Mother’s Title

    Mother’s First Name

    Mother’s Last Name (if different)

    Home Address (if different) Suite #

    City (if different)

    Postal Code (if different)

    Home Telephone (if different) (format xxx-xxx-xxxx)

    Mother’s Occupation

    Work Address

    Work Telephone (format xxx-xxx-xxxx)

    Cell Phone (format xxx-xxx-xxxx)

    E-mail

    Emergency Contact Information


    Name of Family Doctor

    Telephone of Family Doctor (format xxx-xxx-xxxx)

    Address of Family Doctor

    OHIP Number

    Emergency Contact #1


    Name

    Telephone (format xxx-xxx-xxxx)

    Address

    Relationship

    Emergency Contact #2


    Name

    Telephone (format xxx-xxx-xxxx)

    Address

    Relationship

    Synagogue/Religious Affiliation


    To what Synagogue does your family belong?

    Who is your family’s Rabbi?

    Applicant’s Siblings

    Name




    Age




    School




    Grade




    Schools Applicant Attended Since Grade One

    School




    Year




    Camps Applicant Attended

    Camp




    Years Attended




    Youth Group Membership/Extra-Curricular Activities/Sports Leagues

    Activity




    Years Attended




    Heath Questionnaire - To Be Completed by Parents

    Is your son presently under the care of a health-care professional (e.g. physician, orthodontist, psychiatrist, psychologist, physical therapist)?
    YesNo

    If yes, for what condition?

    Does your son currently take any medication?YesNo

    If yes, what is the drug and what are the supervision requirements?

    Has your son experienced learning/behavior difficulties?YesNo

    If yes please explain.

    Has he ever been assessed for ADD/ADHD or learning disabilities? YesNo

    If yes, please explain.

    Please send any written reports you may have together with Part 2 of the Application.

     
     

    Has your son required medication in the past for behavior or learning problems (e.g. ADHD)? YesNo

    If yes, please explain.

    Has your son received any of the following services – either privately or in school – within the past three years:
    speech or language therapy, occupational therapy, physical therapy,
    psychological services, or special education intervention? YesNo

    If yes please explain.

    Are there any medical concerns that would preclude full participation in Yeshiva activities including overnight programs?
    YesNo

    If yes please explain.

    Has the applicant ever suffered from the following?

    Respiratory

    Frequent ColdsChronic CoughsBronchitisAsthmaPneumoniaTuberculosis

    Endocrine

    DiabetesThyroid

    Cardiovascular

    Heart TroubleRheumatic FeverCirculation Problem

    Allergies

    Hay FeverAntibioticsInsect BitesFoodsOther

    Central Nervous System

    HeadachesDizzinessConvulsionsEpilepsyFaintingEar/Eye problems

    Urinary Tract

    Kidney ProblemsBladder Infections

    Infective

    PolioGlandular FeverMumpsMeaslesRubellaChicken Pox

    Gastro-Intestinal

    Bowel ProblemsStomach Problems

    Psychological/Psychiatric

    HyperactivityEating DisordersSleep walkingOthers

    Please enter your Full name and Email address in the fields below. By submitting this form you agree that all the information is accurate to the best of your knowledge.


    Your full name: Email address: