Elementary / Middle School Enrollment Application

Name(Required)

First Last

Email(Required)

Phone

My Child is(Required)

Re-enrolling in Spivak Hebrew Academy

a new Student to Spivak Hebrew Academy

Last Name (Child)

First Name (Child)

Middle Name (Child)

Child's Hebrew Name

Gender (Child)

Date of Birth (Child)(Required)

I am Applying for(Required)

Age as of 9/1/2025

Address

Street Address City State / Province / Region ZIP / Postal Code

Mother's Name

First Last

Mother's Cell

Mother's Email

Mother's Occupation

Father's Name

First Last

Father's Cell

Father's Email

Father's Occupation

List All Medical/Food Allergies

Authorized Persons to Pick up In Case of Emergency

Signature

Parent Name

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