Education Information

Mental Health

Authorization and Payment

Student Information

First Name *

Last Name *

Address *

City *

Zip*

Home Phone *

Cell Phone*

Email *

Date of Birth *

Applicant Full Tehillim Name (Student name and mother name) *

Place of Birth *

Upload Current Photo of Applicant In .jpg or .png format *

Upload

Family Information

Father Information

Name *

Address *

City *

Zip *

Cell *

Email *

Occupation *

Mother Information

Mother Name *

Address *

City *

Zip *

Cell *

Email *

Occupation *

Parents Marital Status *

Married

Divorced

Other

Family Synagogue *

Education

Elementary School *

Years Attended *

Grades Completed *

High School *

Years Attended *

Grades Completed *

Level of Math Skills? *

Good

Fair

Beginner

Level of Science Skills? *

Good

Fair

Beginner

Level of English Skills? *

Good

Fair

Beginner

In order to gain a more complete understanding of our applicants, we request that you write a statement including your personal history, attitudes towards Judaism, future goals and other information that you feel would be helpful to us in considering your application. *

Where did you hear about Bnot Chaya Academy, and why do you want to attend? *

In what ways do you hope to grow from the program? *

What are your afternoon plans for the upcoming year? *

List any talents, interests and hobbies that you have *

How did you spend the last three summers?

Previous Summer 1 *

Previous Summer 2 *

Previous Summer 3 *

Mental Health

Have you ever been in therapy? *

Yes

Do you currently have a therapist? *

Yes

Have you ever been hospitalized or in a therapeutic placement? If yes, When? *

Do you have a psychiatrist?
If yes, please write below name and number and send in a release form to bnotchaya@ymail.com *

Do you have a diagnoses? Are you currently on any medications? If yes, Please specify. *

Do you take any substances? (marijuana, alcohol or any other substances) *

Yes

Other

What are some therapeutic goals you would like to work on this year? (ex: relationship skills, emotional regulation, coping skills, social skills, ect...) *

Authorization and Payment

Authorization for Release of Information

After completing the online application, you will be sent a link to a required authorization form.

I hereby submit my application to Bnot Chaya Academy, and undertake to comply with all rules, regulations and standards set by the school. I certify that all the statements made in this application are complete and accurate to the best of my knowledge.
Enter your name below as your signature.

There is a $150.00 application fee.

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