4 Children - Online Application

Online Application

2025-2026
Family Name*
What year are you applying for?*
Student #1 Information
Child*

First NameMiddle NameLast Name
Hebrew Name
Gender*
Date of Birth*

MonthDayYear
Hebrew Birthday
Child/Childrens Address*
Application for Grade*
Current School*
Current Teacher*
Current Teacher Contact*
Has your child ever had a psychological or educational evaluation (by a school, privately, or by the Department of Education)?*
Does your child receive any of the following services?*

Occupational TherapySpeech TherapyPhysical TherapyCounselingP3/SeitParaprofessional/ShadowNone
Does the applicant have any particular disabilities or have they experienced any serious illness or accident? If yes, please explain.*
What are your child's areas of strength (academically, socially, emotionally)?*
What areas (academically, socially, emotionally) does your child struggle in?*
Please upload the following documents
Recent Photograph*

Cancelof
Birth Certificate*

Cancelof
Current IEP/Evaluation

Cancelof
Report Card/Progress Report*

Cancelof

Student #2 Information
Child*

First NameMiddle NameLast Name
Hebrew Name
Gender*
Date of Birth*

MonthDayYear
Hebrew Birthday
Child/Childrens Address*
Application for Grade*
Current School*
Current Teacher*
Current Teacher Contact*
Has your child ever had a psychological or educational evaluation (by a school, privately, or by the Department of Education)?*
Does your child receive any of the following services?*

Occupational TherapySpeech TherapyPhysical TherapyCounselingP3/SeitParaprofessional/ShadowNone
Does the applicant have any particular disabilities or have they experienced any serious illness or accident? If yes, please explain.*
What are your child's areas of strength (academically, socially, emotionally)?*
What areas (academically, socially, emotionally) does your child struggle in?*
Please upload the following documents
Recent Photograph*

Cancelof
Birth Certificate*

Cancelof
Current IEP/Evaluation

Cancelof
Report Card/Progress Report*

Cancelof

Student #3 Information
Child*

First NameMiddle NameLast Name
Hebrew Name
Gender*
Date of Birth*

MonthDayYear
Hebrew Birthday
Child/Childrens Address*
Application for Grade*
Current School*
Current Teacher*
Current Teacher Contact*
Has your child ever had a psychological or educational evaluation (by a school, privately, or by the Department of Education)?*
Does your child receive any of the following services?*

Occupational TherapySpeech TherapyPhysical TherapyCounselingP3/SeitParaprofessional/ShadowNone
Does the applicant have any particular disabilities or have they experienced any serious illness or accident? If yes, please explain.*
What are your child's areas of strength (academically, socially, emotionally)?*
What areas (academically, socially, emotionally) does your child struggle in?*
Please upload the following documents
Recent Photograph*

Cancelof
Birth Certificate*

Cancelof
Current IEP/Evaluation

Cancelof
Report Card/Progress Report*

Cancelof

Student #4 Information
Child*

First NameMiddle NameLast Name
Hebrew Name
Gender*
Date of Birth*

MonthDayYear
Hebrew Birthday
Child/Childrens Address*
Application for Grade*
Current School*
Current Teacher*
Current Teacher Contact*
Has your child ever had a psychological or educational evaluation (by a school, privately, or by the Department of Education)?*
Does your child receive any of the following services?*

Occupational TherapySpeech TherapyPhysical TherapyCounselingP3/SeitParaprofessional/ShadowNone
Does the applicant have any particular disabilities or have they experienced any serious illness or accident? If yes, please explain.*
What are your child's areas of strength (academically, socially, emotionally)?*
What areas (academically, socially, emotionally) does your child struggle in?*
Please upload the following documents
Recent Photograph*

Cancelof
Birth Certificate*

Cancelof
Current IEP/Evaluation

Cancelof
Report Card/Progress Report*

Cancelof

Family Information
Father/Guardian 1*
Citizenship Status*
Is father a convert? If yes, please list the officiating Rabbi*
Mother/Guardian 2
Citizenship Status*
Is mother a convert? If yes, please list the officiating Rabbi*
Siblings

NameAgeCurrent School
NameAgeCurrent School
NameAgeCurrent School
NameAgeCurrent School
Are both biological parents living?*
Student resides with*
Parents marital status*
Languages spoken at home*
Family Religious Level*
What is your hashkafa/guiding philosophy about Judaism and Jewish education?*
Level of Observance*

Shomer ShabbatKashrutAttends Synagoge RegularlyAttends Synagoge on High Holidays Only
Maternal Family*
Paternal Family*

I hereby apply for membership and enrollment for the 2025-2026 school year for my child/children as a student at Mill Basin Yeshiva Academy, a school accredited by the state of New York. The application fee is paid to process my application and interview. The application fee is non-refundable. This fee is not a registration or enrollment fee.

By submitting this application with my credit card details, I am accepting the non-refundable fee terms.
Parent/Guardian Name*

First NameLast Name
Today's Date*

MonthDayYear

My Products

Application Fee x 4

$500.00

Total

$0.00

Credit Card

Apple Pay

Google Pay

Online Application