BTC Early Childhood Inquiry Form - Form - B'nai Torah Congregation

As the only NAEYC accredited Jewish educational program in South Palm Beach County, The Ruth and Edward Taubman Early Childhood Center at B'nai Torah is "The Smartest Choice in Early Childhood Education." Our unique, developmentally appropriate curriculum provides a healthy self-image and independence for your child in a warm, welcoming environment.

Everyone must provide proof of state mandated immunization for admission.
No exceptions.

Today's Date:

Are you a Member of B'nai Torah?

YesNo

How did you hear about our program?

* Guardian #1 - First Name

* Guardian #1 - Last Name

* Guardian #1 - Email Address

* Guardian #1 - Mobile Phone

* Address

* City

* State

* Zip Code

* Is there a Guardian #2?

* Guardian #2 - First Name

* Guardian #2 - Last Name

* Guardian #2 - Email Address

* Guardian #2 - Mobile Phone

* Does Guardian #2 live at the same address?

* Guardian #2 - Address

* Guardian #2 - City

* Guardian #2 - State

* Guardian #2 - Zip Code

* How many preschool age children are in your household?

Child 1 - First Name

Child 1 - Last Name

Child 1 - Date of Birth

Child 1 - Gender

Program of interest:

* Has your child received all state-mandated vaccines?

Please Select OneYesNo

Please be aware that we do NOT accept religious exemption.

* Is your child currently enrolled in another program?

Please Select OneNoYes

* Does your child receive any early intervention?

Please Select OneNoYes

* Please tell us more about your child:

Please share any information that will help to give us a general "snapshot" of your child. You may also elaborate here regarding interventional therapy that your child receives, if any.

Child 2 - First Name

Child 2 - Last Name

Child 2 - Date of Birth

Child 2 - Gender

* Program of interest:

* Has your child received all state-mandated vaccines?

Please Select OneYesNo

Please be aware that we do NOT accept religious exemption.

* Is your child currently enrolled in another program?

Please Select OneNoYes

* Does your child receive any early intervention?

Please Select OneNoYes

Please tell us more about your child:

Please share any information that will help to give us a general "snapshot" of your child. You may also elaborate here regarding interventional therapy that your child receives, if any.

Child 3 - First Name

Child 3 - Last Name

Child 3 - Date of Birth

Child 3 - Gender

* Program of interest:

* Has your child received all state-mandated vaccines?

Please Select OneYesNo

Please be aware that we do NOT accept religious exemption.

* Is your child currently enrolled in another program?

Please Select OneNoYes

* Does your child receive any early intervention?

Please Select OneNoYes

Please tell us more about your child:

Please share any information that will help to give us a general "snapshot" of your child. You may also elaborate here regarding interventional therapy that your child receives, if any.