Registration form – Kineret Tamim Academy of Victoria

Student Information

Student's name

First

Last

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Student’s date of birth

Place of birth

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Grade applying for

School year applying for

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Street address

City

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Province

Postal code

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Status in Canada

Primary language spoken at home

Household Information

Parent/Guardian 1

This parent/guardian will be the primary contact we will use for your application

Name

First

Last

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Relationship to the student

Marital status

Address same as student (if different, please fill out below)

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Street address

City

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Province

Postal code

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Email address

Home phone

Occupation

Cell phone

Work phone

Status in Canada

Parent/Guardian 1 lives with the student?

Yes
No

Parent 2/ Guardian

Name

First

Last

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Relationship to the student

Marital status

Address same as student (if different, please fill out below)

P2 Street

Street address

City

P2 State

Province

Postal code

Parent 2

Email address

Home phone

Occupation

Cell phone

Work phone

Status in Canada

Parent/Guardian 2 lives with the student?

Yes
No

Parent/Guardian 2 wants to receive correspondence?

Yes
No

General information

Tell us more about your child and family

Describe the relationship you would like to have with your child’s teachers and the community

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Does your child have an IEP, or private neuropsychological or psycho-educational evaluation, and/or does your child currently receive any related service such as speech therapy, special education services or counseling?

Does your child have a medical condition that requires management, medication, and/or care at school (including allergies, asthma, diabetes, seizures, etc)?

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Is there anything else you would like us to know about your child?

Is your family affiliated with a congregation? If yes, which one?

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Are there any conversions in the family?

Yes
No

If there are conversions, please provide details:

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If applicable, legal custody agreement?

If applicable, proof of guardianship through BC Judicial process ?

Sibling information

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Name

Age

School attending

Information about current school/preschool

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Name of current school / preschool

School / preschool phone number

I consent for Kineret Tamim Academy to contact with the teacher/principal of my child's current school for references

Yes
No

I understand that acceptance of my child to Kineret Tamim Academy does not mean they will be able to have a Bat or Bar Mitzvah at the Chabad family Shul.

Yes