Child's Information

Child's First name

Child's Middle Name

Child's Last name

Child's Hebrew Name

Child's Nickname

Child's Date of Birth

Child's Sex

Male

Female

My child has not been born yet

Child's Home Phone

Child's Home Address

Child's City

Child's State/Region

Child' Postal Code

Child's Country

Please Upload a Recent Photo of Your Child

Today's Date

Design Your Child's Schedule

Summer only applications should STOP here and fill out the Summer only form: CLICK HERE

How old will your child be at school start date?

Projected School Start Date

I am signing my child up for:

Fall 2026

Both Summer & Fall 2026

Fall 2027

Both Summer & Fall 2027

Desired Summer Schedule

8 Weeks

9 Weeks

Child's Primary Physician

Physician's Phone Number

Known Allergies

Does Your Child Have a Medical Condition?

Yes

No

Does your child have any special needs we should be aware of? Please provide the school with your child’s IEP or IFSP, if applicable.

I authorize Passaic Clifton playgroup aka Gan Kochavim Preschool to seek medical care for my child in the event of an emergency

I authorize Passaic Clifton playgroup aka Gan Kochavim Preschool to seek medical assistance for my child

Your Signature

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