New & Prospective Family Intake Form

* Today's Date

* Are you a member of Westchester Jewish Center

* Would you like membership information?

* Child's Name (also nickname)

* Family Name

* Date of Birth

* Gender

Child's Address

City

State

Zip Code

Programs I am interested in:

ECC School Year 2024-25ECC Summer Camp 2024ECC School Year 2023-24

* Parent 1 - First Name

* Parent 1 - Last Name

* Parent 1 - Email Address

* Parent 1 - Mobile Phone

Parent 1 - Occupation

Parent 1 - Business Name

Parent 1 - Business Address

Parent 1 - Business Phone

* Is there a second parent?

* Parent 2 - First Name

* Parent 2 - Last Name

* Parent 2 - Email Address

* Parent 2 - Mobile Phone

Parent 2 - Occupation

Parent 2 - Business Name

Parent 2 - Business Address

Parent 2 - Business Phone

* Does the child have siblings? If yes, how many?

Sibling 1 - Name

Sibling 1 - Date of Birth

Sibling 1 - School Attending (if applicable)

Sibling 2 - Name

Sibling 2 - Date of Birth

Sibling 2 - School Attending (if applicable)

Sibling 3 - Name

Sibling 3 - Date of Birth

Sibling 3 - School Attending (if applicable)

What school are you considering for Kindergarten?

Nanny’s Name (if applicable):

What does your child call their Nanny?

How did you hear of our school?

What do you hope your child will gain from his/her school experience?

What are some of your child’s favorite things? (Toys, Activities, Pets, Etc.)

Is your child toilet-trained? _______ If not, at what stage is your child in this process?

What words to you use to describe bodily functions?

Past experience in Pre-School or Day Camps?

Do you or other family members have interest, skills or hobbies which you would like to share with the children and the staff?

Any family situations or problems which might hinder child’s adjustment?

Additional Information regarding your child's birth you'd like to share:

Additional Information regarding your child's development you'd like to share:

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

Fri, October 11 2024 9 Tishrei 5785