The Mesivta/High School of Yeshivas Chofetz Chaim Talmudical Academy of Baltimore

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

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

______

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

______

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 ______

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:______

______

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? ______

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

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______

______: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 ______