Enrollment Form - PTACH | Jewish Education for students with learning challenges

1Student Info

2Family Info

3Educational Info

4Medical History

5General Behavior

6Goals

Name of P'TACH Program*

All information included herein will remain strictly confidential

STUDENT INFORMATION

Student's Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Age (auto-calculated)

Social Security Number

Home Address*

Street Address Address Line 2 City State ZIP Code

Phone Number (Home)*

Phone Number (Emergency)*

How did you learn about the program?

FAMILY INFORMATION

Father's Name*

Mother's Name*

Father's Business

Mother's Business

Father's Business Address

Street Address City State ZIP Code

Mother's Business Address

Street Address City State ZIP Code

Father's Phone Number*

Mother's Phone Number*

Father's Email*

Mother's Email*

Brothers' Ages

Sisters' Ages

Primary Language Spoken at Home

Synagogue Affiliation

Name of Rabbi

Rabbi's Phone Number

Paternal Grandparents

Paternal Grandparents Address

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

Maternal Grandparents

Maternal Grandparents Address

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

EDUCATIONAL INFORMATION

School History

List the schools your child has attended. (List most recent first.)

School	Address	Grade	Actions

There are no school history added.

Maximum number of school history added reached.

Has any grade been repeated?*

Yes

What Grades were repeated?

If your child has/or is receiving special services from any school, agency, private specialist or clinic.

Yes

Please complete the following:

Reading

Reading Services Dates

Math

Math Services Dates

Speech &/or Language

Speech/Language Services Dates

Religious Studies

Religious Studies Services Dates

Psychological Services

Psychological Services Dates

Has your child had psychological or educational testing?

Yes

Where & When?

MEDICAL HISTORY

Does your child suffer from any illness?

(e.g. Allergies, Sinus Infections, Seizures, or asthma etc.)

Yes

Which

Has your child ever been hospitalized?

Yes

At what age?

Why?

Has your child ever been on medication for control of an attention or behavioral issue?

Yes

Has your child ever been on medication for control of a convulsive disorder?

Yes

What is the name of your child's doctor?

Doctor's Phone

Doctors Address

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

When was your child's last ear, nose, & throat exam?

Month

Day

Year

When was your child's last eye examination?

Month

Day

Year

Does your child wear glasses?

Yes

From what age?

Has your child seen a psychologist or counselor some time in the last four years for counseling?

Yes

Psychologist/Counselor Name

Psychologist/Counselor Address

Street Address City State ZIP Code

GENERAL BEHAVIOR

Easily managed at home?*

Yes

Explanation if necessary

Responsive to adults?*

Yes

Explanation if necessary

Responsive to children their own age?*

Yes

Explanation if necessary

Consistent in behavior from day to day?*

Yes

Explanation if necessary

Able to concentrate?*

Yes

Explanation if necessary

Extremely Active?*

Yes

Explanation if necessary

Easily managed at school?*

Yes

Explanation if necessary

Can work well independently?*

Yes

Explanation if necessary

Appears to be happy in school situation?*

Yes

Explanation if necessary

Has tendency to tune in and tune out of listening situations?*

Yes

Explanation if necessary

Seems to understand things better if he can see them in pictures?*

Yes

Explanation if necessary

Comprehends verbal requests, commands, direction, etc?*

Yes

Explanation if necessary

Wants TV/Radio excessively loud?*

Yes

Explanation if necessary

Has difficulty copying written material?*

Yes

Explanation if necessary

What are your child's interests and hobbies?*

Please indicate below any further information about your child's background (at home and in learning situations) in terms of particular weaknesses and strengths that you feel would be helpful to us in planning an educational program for him/her.

To the best of your knowledge, please describe your child's ability in the following areas:

Reading*

Below

Above

Comments

Writing*

Below

Above

Comments

Arithmetic*

Below

Above

Comments

Hebrew Reading*

Below

Above

Comments

Davening*

Below

Above

Comments

Chumash*

Below

Above

Comments

Gemorah*

Below

Above

Comments

Organization*

Below

Above

Comments

What do you see as the nature of your child's difficulties?

Goals

Why are you referring your child to this program? What are your goals for him/her in this program?

Have you ever visited a P'TACH program?*

Yes

When did you visit a P'TACH program?

At P'TACH, we look for an active parental involvement in the education of the children. What type of input would you like to have in your child's education?

How do you feel about your child being in the P'TACH program?

Upload Documents

In order to process your child’s application we also require:
1. Psychological Evaluation - Intellectual Assessment and Full Personality Profile (completed within the last year)
2. Educational Evaluation (completed within the last year)
3. Statement from child’s present teacher regarding classroom functioning
4. Statement from all professionals currently working with your child
5. All reports previously done on your child
6. Signed release forms

Check off the documents you are ready to upload now:

A recent photo of my child

Psychological Evaluation - Intellectual Assessment and Full Personality Profile (completed within the last year)

Educational Evaluation (completed within the last year)

Statement from child’s present teacher regarding classroom functioning

Statement from all professionals currently working with your child

All reports previously done on your child

Signed release forms

Upload a recent photo of your child*

Drop files here or

Max. file size: 120 MB, Max. files: 1.

Upload Psychological Evaluation - Intellectual Assessment and Full Personality Profile (completed within the last year)*

Drop files here or

Max. file size: 120 MB.

Educational Evaluation (completed within the last year)*

Drop files here or

Max. file size: 120 MB.

Statement from child’s present teacher regarding classroom functioning*

Drop files here or

Max. file size: 120 MB.

Statement from all professionals currently working with your child*

Drop files here or

Max. file size: 120 MB.

All reports previously done on your child

Drop files here or

Max. file size: 120 MB.

Signed release forms

Drop files here or

Max. file size: 120 MB.

Are you ready to pay the Application Fee now?*

Yes, pay by credit card/paypal

No, I will send in a check

Application Fee

Price:

Consent*

All of the information I have given is true and to the best of my knowledge is an accurate description of my child's history and abilities*

Phone

This field is for validation purposes and should be left unchanged.

P'TACH Application

STUDENT INFORMATION

FAMILY INFORMATION

EDUCATIONAL INFORMATION

MEDICAL HISTORY

GENERAL BEHAVIOR

To the best of your knowledge, please describe your child's ability in the following areas:

Goals

Upload Documents

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