The Mesivta/High School of Yeshivas Chofetz Chaim Talmudical Academy of Baltimore
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THE MESIVTA/HIGH SCHOOL OF YESHIVAS CHOFETZ CHAIM TALMUDICAL ACADEMY OF BALTIMORE 4445 Old Court Road Baltimore, MD 21208 Tel: (410) 484-6600 EXT. 303 Fax: (443) 725-2059 Email: [email protected] APPLICATION APPLICATION FOR ADMISSION 1 Date of Application: ___/____/___ Application For Grade: _________ Year Applying For: _____/______ PLEASE ANSWER EVERY QUESTION. PLEASE PRINT. Please have the Educator’s Report filled out and returned to us by your principals. Remittance of a NON-REFUNDABLE application fee of $100.00 is necessary for your application to be processed. Applicant’s Full English Name: ______________________________________________ Applicant’s Full Hebrew Name (in Hebrew): _____________________________________ Name used:___________________________Kohain _____Levi_____Yisroel _________ Date of Birth: ____/____/____ Hebrew Date of Birth: _____________________________ U.S. Citizen Y N Birth Place: ___________________________________ Country Of Citizenship: ____________________________________________________ Social Security #: ___ ___ ___ /___ ____ / ____ ____ ____ ____ Name of School presently attending: _________________________________________ Hebrew Grade _______ Rebbe’s Name___________________ English Grade ________ List all schools previously attended, if any: Name of School Dates of Attendance ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ ________________________________ 2 Does applicant have any current health problems, particular disabilities, or special needs? Yes __ No__ If yes, please specify: _______________________________________________________________________ _______________________________________________________________________ Has the applicant received, or is he currently receiving special medical, psychological or academic help? Yes ___ No ____ (Please give details on a separate sheet of paper to be kept confidential) Has the applicant ever had educational or psychological testing? ____________________ Is child converted or adopted to Judaism? Yes_____ No _____ Was either parent converted or adopted to Judaism? Yes_____ No _____ Were any of the grandparents converted or adopted? Yes _____ No______ Please include (if applicable) date, place and officiating rabbinical authority of adoption or conversion of child, Mother, Father and/or grandparent. (Please enclose, if applicable copies of adoption or conversion papers) If parents are separated, divorced or if either parent is deceased, please indicate. _______________________________________________________________________ If parents are legally separated or divorced, please enclose copies of custodial documentation. If divorced or separated, applicant lives with: ___________________________________ Siblings of applicant Birth dates ______________________ _______________________ ______________________ _______________________ ______________________ _______________________ ______________________ _______________________ 3 1. FATHER’S INFORMATION Father’s Full Name: __________________________________________________ Father’s Hebrew Name: ______________________________________________ Please indicate name you want used for correspondence: ____________________ Please circle: Rabbi Dr. Mr. Home Address: Zip _____________________ Home Telephone: Business Telephone: _____________________ Cell phone___________________ Occupation: _______________________________________________________ Business Address: __________________________________________________ Email Address: _____________________________________________________ Please Check: Kohain Levi Yisroel _________ Hebrew Name of Father’s Father: _______________________________________ Father’s Mother: ____________________________________________________ Applicant’s Paternal Grandparents’ Names and Address: ____________________ __________________________________________________________________ Language Spoken at Home: ___________________________________________ Synagogue Affiliation: ________________________________________________ Are you a T.A. Alumnus? Class of __________________ 4 2. MOTHER’S INFORMATION Mother’s Full Name: __________________________________________________ Maiden Name: ______________________________________________________ Mother’s Hebrew Name:_______________________________________________ Please indicate name you want used for correspondence: ____________________ Home Address:__________________________________ Zip: ________________ Home Telephone: ______________________ Business Telephone: ____________ Cellphone__________________ Occupation:_________________________________________________________ Email Address: ______________________________________________________ Mother’s father is: Kohain Levi Yisroel _______ Hebrew Name of Mother’s Father:_____________________________________ Mother’s Mother:_____________________________________ Applicant’s Maternal Grandparents’ Names and Address:______________________ ___________________________________________________________________ ___________________________________________________________________ 5 3. Indicate the general extent of your knowledge and skills in the following areas: חומש רשי"__________________________________________________________ נך_______________________________________________________ גמרא______________________________________________________ משניות_____________________________________________________ שולחן ערוך__________________________________________________ 4. Mesechta currently learning: ___________________________________________ 5. Have you ever been dismissed from any school? _________________________ If yes, for what reason? ______________________________________________ 6. List any scholarships, prizes, contests, or any others awards you have won: ____________________________________________________________________ 7. What subject(s) do you like best? (secular and limudei kodesh) _____________________ 8. What subject(s) do you like least? (secular and limudei kodesh) _________________ 9. What subject(s) do you find most difficult? _________________________________ 10. What is your ambition in life? __________________________________________ 11. Have you ever had any serious illness? __________________________________ 12. Indicate membership in any school or outside organization: ___________________ _____________________________________________________________________ 13. What summer camps have you attended? ________________________________ 6 14. Indicate parents’ affiliation with any communal, religious or other organization: _______________________________________________________________ Congregation____________________ Address_______________________ Rabbi’s Name____________________________________________________ 15. Who recommended you to our school?______________________________ 16. List a name of a Rebbe or mentor you are closest to: ___________________ Please take note that this application will be processed and your son’s acceptance will be finalized upon the receipt of the following items: 1 – An official transcript for all prior high school grades completed. If the applicant is entering 9th grade, or took high school credits in 8th grade (e.g. Algebra I), we must receive an 8th grade transcript as well. In addition, please remit the student’s last two report cards. 2 – The non-refundable application fee of $ 100.00 must be enclosed. I hereby certify that the above information is complete and accurate. _____________________ __________________________ Date Signature of Applicant ______________________ __________________________ Date Signature of Parent or Guardian 7 EDUCATOR’S REPORT ON APPLICANT NAME OF APPLICANT:_______________________________ We are interested not only in the school record of the applicant, but also in your comments or ratings on each of the following items. Any special information or suggestions about the applicant will, of course, be helpful. A copy of the latest report card is required. All information will be treated as confidential and will be accessible only to the Administrative officers of our Yeshiva. HEBREW DEPARTMENT ENGLISH DEPARTMENT Scholastic Achievement הצטיינות______________________ _______________________________ השתדלנות_________________ Scholastic Ability כשרונות_____ _________________ Effort and Diligence שקידה________________________ Personality and Character הנהגה__________________________ General Behavior מידות אישיות__________________ 8 _______________________:Remarks הערות________________________ Signature__________________ __________________Signature מנהל FOR OFFICE USE ONLY Date Application Received:________________________________________ Date of Interview and Bechina:_____________________________________ Accepted Not Accepted Pending Answer mailed on the following date:_____________________________ Accepted, Registration Received Accepted, not coming ENTRANCE EXAMINATION EVALUATION: Chumash _________________ Gemara ______________ Reading: Vocabulary ____________ Comprehension___________ Math: Concepts_______________ Computation______________ Applications_____________ Composite_______________ Character: __________________________________________________ Personality:__________________________________________________ ADDITIONAL INFORMATION: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 9 _______________________________________________________________________ 10 .