Ida Crown Jewish Academy

Step 1: Applicant Information

For School Year	Entering Grade:	Social Security Number:

Applicant's Name:
Last Name:	First Name:	Middle Name:
Hebrew Name:	Date Of Birth:	Gender: Male Female
Applicant Email:	Place of Birth (City, State or Country):	Immigration Date

School applicant currently attends:
School Name:	School Address:	School State:
Zip Code:	Telephone Number:	Principal's Name:

Other schools attended:
School Name:	Grades completed at this school:
School Name:	Grades completed at this school:

If applicant attends public school, Hebrew school information:
School Name:	Principal's Name:	Number of years attended:
Address:	City:	State:
Zip Code:	Telephone Number:

Please list two references other than the person who will be writing the Letter of Recommendation for the applicant. (Rabbi, principal, teacher, etc.):
Name:	Telephone Number:	Email Address:
Name:	Telephone Number:	Email Address:

Has the applicant ever been evaluated for any educational or social-emotional issue?: Yes No
Who administered the evaluation?	What was the date of the evaluation?
What were the results of the evaluation?
Is the applicant currently receiving support services? Yes, at school Yes, out of school No
If yes, who is providing support?
How many times a week is support being received, and how many minutes of support are received each time?
What areas are being addressed during support?
Does the applicant require any special adaptation within the school environment?

Is the applicant currently under the care of a physician for any illness or injury? Yes No
If yes, what is the name of the physician providing care?
What is the medical condition for which care is being provided?
If any medication has been prescribed, what is the name and dosage being taken?
Please add any additional information that you feel might be helpful for us to know about the applicant:

If you answered yes to any of the above questions, please read “Important Information for Parents of Applicants Who May Require Academic Services,” and complete a Release of Information form for each service provider. Receiving this information will allow our Department of Academic Services to understand the learning needs of the applicant and facilitate class placement and academic support.

Please list the applicant's hobbies or special interests.
Please list any scholastic awards or honors the applicant has received.
Please list any youth organizations in which the applicant is involved.

Please complete the following information regarding summer camps.
Which summer camps has the applicant attended?
Camp Name:	Camp Location:	Dates attended:
Camp Name:	Camp Location:	Dates attended:

Step 2: Applicant's Mother

Last Name:	First Name:	Maiden Name:
Hebrew Name:	Title:	Address:
City:	State:	Zip Code:
Telephone Number:	Cell Phone Number:	Email Address:
Place of Birth:	Occupation:	Work Telephone:
Firm Name:	Fax Number:	Business Address :
City:	State:	Zip Code:

Marital Status
If remarried, spouse's name:
Is applicant's mother Jewish by birth? Yes No
Is applicant's mother's mother Jewish by birth? Yes No
If applicant's grandparents, parents or applicant are not Jewish by birth, please provide certificate of Halachic conversion.

Step 3: Applicant's Father

Last Name:	First Name:	Title:
Address:	City:
State:	Zip Code:
Telephone Number:	Cell Phone Number:	Email Address:
Hebrew Name:	Kohain Levi Yisrael
Place of Birth:	Occupation:	Work Telephone:
Firm Name:	Fax Number:	Business Address :
City:	State:	Zip Code:

Marital Status
If remarried, spouse's name:
Is applicant's father Jewish by birth? Yes No
Is applicant's father's mother Jewish by birth? Yes No

Step 4: Applicant's Grandparents

Applicant's Maternal Grandparents
Last Name:	First Name:	Title:
Address:	City:	State:
Zip Code:	Telephone Number:	Email Address:

Last Name:	First Name:	Title:
Address:	City:	State:
Zip Code:	Telephone Number:	Email Address:

Applicant's Paternal Grandparents
Last Name:	First Name:	Title:
Address:	City:	State:
Zip Code:	Telephone Number:	Email Address:

Last Name:	First Name:	Title:
Address:	City:	State:
Zip Code:	Telephone Number:	Email Address:

If applicant lives with someone other than parents:
Name of person with whom applicant resides:		Relationship to Applicant:
Address:	City:	State:
Zip Code:	Telephone Number:	Email Address:

Step 5: Applicant's Siblings

Applicant's Siblings
Name:	Gender: Male Female	Grade:
School Information:

Name:	Gender: Male Female	Grade:
School Information:

Step 6: Additional Information

Additional Information
Have any members of the family attended the Academy? If yes, please list names and graduation years:
Does your family attend synagogue regularly on Shabbat and holidays?: Yes No
Name of Synagogue:	Would you describe your family as Shabbat observant?: Yes No
Does the applicant daven regularly on days other than Shabbat? Yes No
Does your family observe Kashrut? Yes No	At home Outside home

Emergency Contact Information:
Name:	Telephone Number:	Relationship to applicant:
Name:	Telephone Number:	Relationship to applicant:

Signatures
Applicant Signature:	Date:
I verify that the information provided is true and correct.

Signature of Parent/Guardian:	Date:
I verify that the information provided is true and correct.

Signature of Parent/Guardian:	Date:
I verify that the information provided is true and correct.

Important Information for Parents of Applicants Who May Require Academic Services
The mission of Ida Crown Jewish Academy Department of Academic Services is to create an educational environment that meets the needs of applicants who have been identified as having a specific learning disability. The identification of a applicant’s academic strengths and weaknesses is critical for enhancing his/her potential within the learning environment. Therefore, it is required that a full psycho-educational evaluation report, which includes results from the Wechsler Intelligence Scale for Children (WISC-IV), a complete Woodcock Johnson III or WIAT achievement battery, and a Woodcock-Johnson III Cognitive assessment of information processing be submitted to the school office. The date of this evaluation should be within two years of application. It is important to note that eligibility for testing accommodations (i.e. extended time, oral testing, and multiple day testing) for ACT, SAT and AP tests requires a current evaluation and a record of academic services. In the event that an evaluation has not been completed, the Department of Applicant Academic Services is available to assist in the location of appropriate public and private testing sources. The department does require parental cooperation in obtaining information from physicians, therapists, and other service professionals involved in the applicant’s care. After the evaluation report has been submitted, the Academic Services staff, in conjunction with Academy administration, will develop an educational plan to address the applicant’s learning needs. The parents and applicant will be asked to meet with the Academic Services staff to discuss the creation and implementation of this plan. Each applicant will be expected to attend all scheduled support sessions, and to make a commitment of at least 1-2 academic hours per day outside school for homework. Parents are expected to provide a supportive environment to encourage academic discipline and effort. In addition, the staff of our College Guidance Department will be available to assist applicants who have been identified with learning needs in the application for accommodations on the ACT, SAT and AP tests. If you have any further questions regarding requirements for psychoeducational testing at ICJA, please contact Mr. Ariel Zamarripa at (773) 973-1450 x 142.

Admission Application