Becker Admissions Application

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Child Information

* Child's First Name

* Child's Last Name

* Date of Birth (MM/DD/YYYY):

If your child is not yet born, please list the expected due date, then skip to Parent Information

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?

* Please list any medical or developmental concerns the school should be aware of, including any current therapies, allergies, or educational support for your child.

* Applicant is a: (select all that apply)

Congregation Emanu El MemberSibling of a current Becker studentSibling of a former Becker studentNew applicant

* Class Preferred (please select)

For Infant Class (7:30 a.m. - 5:30 p.m.) YEAR-ROUND

For Young Toddlers Class (9:00 a.m.-12:30 p.m. or 9:00 a.m.-2:30 p.m.)

For TWOS (9:00 a.m. - 12:30 p.m. or 9:00 a.m. - 2:30 p.m.)

For THREES (9:00 a.m. - 12:30 p.m. or 9:00 a.m. - 2:30 p.m.)

For PreK (9:00 a.m. - 2:30 p.m.)

For Kindergarten (9:00 a.m. - 2:30 p.m.)

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)

Total:

Fri, March 14 2025 14 Adar 5785

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