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Application

P'TACH Application

Download the printable form

"*" indicates required fields

1Student Info
2Family Info
3Educational Info
4Medical History
5General Behavior
6Goals
All information included herein will remain strictly confidential

STUDENT INFORMATION

Student's Name*
MM slash DD slash YYYY
Home Address*

FAMILY INFORMATION

Father's Business Address
Mother's Business Address
Paternal Grandparents Address
Maternal Grandparents Address

EDUCATIONAL INFORMATION

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

Please complete the following:

Has your child had psychological or educational testing?

MEDICAL HISTORY

Does your child suffer from any illness?
(e.g. Allergies, Sinus Infections, Seizures, or asthma etc.)
Has your child ever been hospitalized?
Has your child ever been on medication for control of an attention or behavioral issue?
Has your child ever been on medication for control of a convulsive disorder?
Doctors Address
When was your child's last ear, nose, & throat exam?
When was your child's last eye examination?
Does your child wear glasses?
Has your child seen a psychologist or counselor some time in the last four years for counseling?
Psychologist/Counselor Address

GENERAL BEHAVIOR

Easily managed at home?*
Responsive to adults?*
Responsive to children their own age?*
Consistent in behavior from day to day?*
Able to concentrate?*
Extremely Active?*
Easily managed at school?*
Can work well independently?*
Appears to be happy in school situation?*
Has tendency to tune in and tune out of listening situations?*
Seems to understand things better if he can see them in pictures?*
Comprehends verbal requests, commands, direction, etc?*
Wants TV/Radio excessively loud?*
Has difficulty copying written material?*

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

Reading*
Writing*
Arithmetic*
Hebrew Reading*
Davening*
Chumash*
Gemorah*
Organization*

Goals

Have you ever visited a 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:
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                Are you ready to pay the Application Fee now?*
                Consent*
                *
                This field is for validation purposes and should be left unchanged.
                • 1689 East. 5th St, (Cor Ave P)
                  Brooklyn, N.Y. 11230
                • (718) 854-8600
                • [email protected]

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                • Chaim Berlin
                • Bais Yakov D'Rav Meir
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