Cohen Religious School Intake Form

* Family Name

Todays date

* Current School Year

* Address

* City

* State

* Zip Code

* Home/Cell Phone

* How many students are being enrolled?

* Student 1 - First name

* Student 1 - Last name

* Student 1 - Date of Birth

* Student 1 - Gender

* Student 1 - Grade in the Fall of this school year

* Student 2 - First name

* Student 2 - Last name

* Student 2 - Date of Birth

* Student 2 - Gender

* Student 2 - Grade in the Fall of this school year

* Student 3 - First name

* Student 3 - Last name

* Student 3 - Date of Birth

* Student 3 - Gender

* Student 3 - Grade in the Fall of this school year

* Parent/Guardian 1 - First Name

* Parent/Guardian 1 - First Last

* Parent/Guardian 1 - Email

* Parent/Guardian 1 - Cell Phone

* Parent Birthdate

* Is there a second parent or guardian?

* Parent/Guardian 2 - First Name

* Parent/Guardian 2 - First Last

* Parent/Guardian 2 - Email

* Parent/Guardian 2 - Cell Phone

* Does Parent 2 live at the same address as Parent 1?

Parent/Guardian 2 - Address

Parent/Guardian 2 - City

Parent/Guardian 2 - State

Parent/Guardian 2 - Zip Code

Parent Birthdate

Wed, July 3 2024 27 Sivan 5784