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Becker Admissions Application
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Child Information
*
First Name
*
Last Name
*
Date of Birth (mm/dd/yyyy)
*
Male/Female
Please Select One
Male
Female
*
Current School
*
Street Address
*
City
*
State
*
Zip
Parent 1 Information
*
Parent 1 First Name
*
Parent 1 Last Name
*
Parent 1 Email
Address (if different)
City
State
Zip
*
Cell Phone
(###-###-####)
*
Home Phone
(###-###-####)
Employer
Parent 2 Information
Parent 2 First Name
Parent 2 Last Name
Parent 2 Email
Address (if different)
City
State
Zip
*
Cell Phone
(###-###-####)
Home Phone (if different)
(###-###-####)
Employer
Applicant Information
*
How did you hear about Becker?
*
Applicant is a: (select all that apply)
Congregation Emanu El Member
Sibling of a current Becker student
Sibling of a former Becker student
New applicant
*
Class Preferred (please select)
Please Select One
Young Toddlers Class (15 months & walking by Sept. 1)
Twos (2 years old by Sept. 1)
Threes (3 years old by Sept. 1)
Pre-K (4 years old by Sept. 1)
Kindergarten (5 years old by Sept. 1)
Extended Care (available for all ages)
For Young Toddlers Class (9:00 a.m.-12:30 p.m. or 9:00 a.m.-2:30 p.m.)
Please Select One
3-Day Young Toddlers Class (M/W/F)
5-Day Young Toddlers Class (M-F)
For TWOS (9:00 a.m. - 12:30 p.m. or 9:00 a.m. - 2:30 p.m.)
Please Select One
3-Day Twos Class (M/W/F)
5-Day Twos Class (M-F)
For THREES (9:00 a.m. - 12:30 p.m. or 9:00 a.m. - 2:30 p.m.)
Please Select One
5 Day Threes Class (M-F)
For PreK (9:00 a.m. - 2:30 p.m.)
Please Select One
5-Day PreK Class (M-F)
For Kindergarten (9:00 a.m. - 2:30 p.m.)
Please Select One
5 Day Kindergarten Class M-F
Early Care or Extended Care (select all that apply)
Early Care (7:45 a.m. - 9:00 a.m.)
Extended Care (2:30 p.m. - 5:30 p.m.)
*
Acknowledgment of Fee ($25)
Acknowledgment of Fee ($25)
Total:
Tue, October 15 2024 13 Tishrei 5785