Venue : Not fixed yet ! z- Grade 9 Application Form-OLD 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: Δ
