2009 Preschool Cheder Intake Form

Child’s Name ______

Age in October 2009 ______Birth Date ______

School or Play Group (if any) ______

Diagnosis (if any) ______

Please describe your child’s current hobbies or areas of interest______

______

Please list any activities, which your child has expressed, any apprehension regarding his/her participation ______

______

Is your child currently receiving any Judaism-based instruction? No Yes

If yes, please specify ______

Describe areas of strength in secular studies______

______

Describe areas of weakness in secular studies______

______

Describe areas of strength in Judaic studies ______

______

Describe areas of weakness in Judaic studies______

______

What would you like your child to gain from his/her preschool cheder experience? ______

______

How does he/she feel about attending cheder? ______

______

How does your child respond to new places, new situations and meeting new children and adults? ______

______

Does your child have any fears that we should know about?  No  Yes If yes, please describe ______

______

______

Please list any conditions, limitations and/or allergies (asthma, bee stings, food allergies, & motion sickness) ______

______

Is your child potty trained?  No  Yes

Does your child ask to use the bathroom?  No  Yes

Description of child’s most recent diagnosis (if any) ______

Describe problems, if any, that your child may have with peers or adults. What techniques are the most successful in helping your child work through these problems?

Peers ______

Techniques ______

Adults ______

Techniques ______

Please indicate the effectiveness of the following strategies when working with your child on a scale of 1-5, with 1 being the least effective and 5 being the most effective.

Least effectiveMost effective

Light, gentle touch12345

Applying deep pressure12345

Ignoring disruptive behavior12345

Least effectiveMost effective

Redirecting disruptive behavior12345

Providing structure12345

Cuing for eye contact12345

Sitting on wedge seats12345

Rewarding good behavior 12345

If effective, how do you reward the behavior? ______

Soothing music12345

Speaking to child on his/her level12345

The use of visuals12345

Asking multiple choice questions12345

(e.g. Do you want theblue one or the red one?)

Please list any additional strategies that are helpful for your child ______

______

Please list all therapies your child receives:

TherapySessions per weekLength of session

1.

2.

3.

4.

5.

6.

Name of anyone other than the child’s parent who may pick up him/her from cheder

Name ______Relationship______Phone ______

Name ______Relationship______Phone ______

List food restrictions and special dietary needs ______

______

______

Any other comments you would like to share:

Parent Signature ______Date ______

Student Information

(Please Complete One Form per Child)

Child’s Name______Nickname ______

Street Address______

City______State______Zip______

Gender M___F___ Birth date______

Family Information

Parents’ Names ______

Address______Home Phone______

Address______

Email______Cell Phone______

Emergency Information

Emergency Contact #1______Emergency Contact #2______

Relationship ______Relationship ______

Home Phone______Home Phone______

Work Phone______Work Phone ______

Cell Phone______Cell Phone______

Billing Information – Tuition is $20.00 per class with a monthly commitment required. A $20.00 registration fee (which will be applied toward tuition) and registration forms are due by October 9, 2009. Please deliver to Avigael Wodinsky at 1434 Lively Ridge Road. Payment is due the first class of each month for the entire month. No refunds will be given. Checks should be made out to Laura Chefer.

I would like to enroll my child for the following sessions.

_____October 18, 25

_____November 1, 8, 15, 22

_____December 6, 13, 20

Upon completing this registration I acknowledge that I have read and understand the Parent/ Guardian Consent form and that all information is true and correct.

Parent/Guardian Signature______Date______

POLICIES

Registration is available on a first-come first-served basis. If a class reaches capacity, a waiting list will be developed.

Absences: There are NOrefunds or make up days for absences due to illness, vacation or other reasons.

Classes will meet on Sundays from 10:30 a.m. to 11:45 a.m. Please be prompt!

The session will be cancelled and all monies returned should a minimum of 6 students not be reached.

Please include the following information with your registration form:

  • Copy of child’s most recent IEP (if applicable)
  • Copies of any current treatment goals (if applicable)

Emergency Medical and Liability Release

I, the undersigned, am the parent/legal guardian of ______, who is enrolled in the Sunday school program.

By signing this document, I confirm that:

  1. I wish to have my child registered in the Sunday school program and to have him/her participate in any activities during the program;
  2. I release the program, it’s directors, teachers, employees and volunteers assisting during the school sessions from any liability in connection with my child’s participation in any events and activities of the program, which includes, without limitation, any liability related to an accident, an injury or illness suffered by my child;
  3. I authorize the programand persons associated therewith to consent to medical treatment for my child, to select the medical personnel, hospitals and/or clinics to treat my child in case of any accident, injury or illness that may occur;
  4. In the event of an emergency, I authorize the program to contact my child’s doctor, to administer first aid, to take my child to a clinic or hospital (emergency room) or to take any other action deemed necessary by the school or its employees.

Physician’s Name ______

Physician’s Phone Number______

______

Signature of Parent or GuardianDate

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