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New & Prospective Family Intake Form
Please verify reCaptcha before submitting the form.
*
Today's Date
*
Are you a member of Westchester Jewish Center
Please Select One
Yes
No
*
Would you like membership information?
Please Select One
Yes
No
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Child's Name (also nickname)
*
Family Name
*
Date of Birth
*
Gender
N/A or Unknown
Male
Female
Child's Address
City
State
Zip Code
Programs I am interested in:
ECC School Year 2025-26
ECC Summer Camp 2025
ECC School Year 2024-25
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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?
Please Select One
Yes
No
*
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?
Please Select One
No siblings
One sibling
Two siblings
Three siblings
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:
Do you have any concerns about your child’s development?
Hearing
Vision
Language
Gross Motor
Fine Motor
Emotional
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?
Wed, March 19 2025 19 Adar 5785
