1. education
2. school

REGISTRATION INFORMATION FOR THE UPCOMING SCHOOL YEAR
We are looking forward to successful chinuch partnership between your family and Yeshiva Darchei Noam throughout
the upcoming school year and beyond.
Please read this information and the following Checklist of Items Required for Registration carefully. Some of the items
are generic forms which appear on the pages following the checklist, but your family's tuition contract, emergency
contact information and consent form are personalized forms which were sent as a separate email attachment.
A complete school calendar, the YDN parent handbook and other information (seforim lists, school supply lists, etc…) will
be available on our website www.darcheinoam.org under the “Parent Resources” tab by the end of June.
Please submit your completed registration to the Business Office by May 31, 2015.
REGISTRATION DISCOUNT: SAVE MONEY BY REGISTERING ON TIME! To show our appreciation to
parents who submit their forms in a timely fashion and help facilitate a smooth registration process, YDN is once again
instituting a DISCOUNT of $200 PER STUDENT for families who submit all the items required for registration by May 31st.
FACTS/TUITION PAYMENT POLICY: The FACTS payment program has greatly enhanced the financial stability of the
Yeshiva and YDN is continuing its partnership with FACTS for the 2015-2016 school year.
 If you are a new parent, you can set up your Yeshiva Darchei Noam FACTS account by using the following URL:
https://online.factsmgt.com/signin/3G52Q.Please note: FACTS has a 2.75% fee for payments made with a credit
card. There is no fee for payments made with a checking account. For more information about FACTS, please
visit their website or download the FACTS information flyer available at www.darcheinoam.org/registration.
 If you are a returning parent and already have a FACTS account but would like to make changes to your
banking information, you can do so by accessing your FACTS account online or by calling (866) 441-4637.
ADMITCARDS: In August, admission cards will be mailed to all students whose families have completed the Registration
process and are financially clear. These admit cards are needed for NIT-checking and the first day of school.
BREAKFAST/LUNCH: The tuition fees do not include the cost of breakfast or lunch.
 The breakfast program (grades 6-8 only) is prepared in-house. Please see the attached breakfast form and
submit it to the Business Office if you want your son/s to participate in the breakfast program. Enrollment for the
breakfast program is for 5 months at a time.
 The lunch program is operated by a third party caterer and information about the lunch program will be sent out
as it becomes available.
MEDICAL FORMS: Please see the Message from the Nurse's office (page 5)
TUITION ASSISTANCE: Yeshiva Darchei Noam will only be able to fund a very limited number of tuition scholarships based on both
availability and need and scholarships are awarded on a first come – first served basis. To request financial assistance, please
download the Tuition Assistance Application available on www.darcheinoam.org/registration. Tuition Assistance Application received by
st
the Business Office by May 31 , with the registration fee and all required forms, still qualify for the registration discount.
PLEASE NOTE: Unfortunately, Tuition Assistance Applications received after the May 31st deadline will incur an additional processing fee:
o
Tuition Assistance applications submitted after May 31, 2015 must be accompanied with $75.00 late processing fee.
o
Tuition Assistance Applications submitted after June 19, 2015must be accompanied with a $150.00 late processing fee.
If you have any questions, please contact the Business Office.
(845) 352-7100, ex. 108
businessoffice@darcheinoam.org
Business Office Summer Hours: Monday –Thursday: 9:30 – 1:30
The Business Office will be CLOSED for two weeks over the summer.
Please call the Business Office before stopping by to confirm the office is open.
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CHECKLIST OF ITEMS REQUIRED FOR REGISTRATION
Registration Forms can be submitted by mail, fax or email:
MAIL: YDN, Attn: Business Office, 257 Grandview Ave., Suffern, NY 10901;
FAX: 845-352-9593 – Attn: Business Office; EMAIL: businessoffice@darcheinoam.org.
To ensure that all your forms reach their appropriate destination, please submit all forms at one time.
An ‘*’ below indicates that this is a personalized form that is in the accompanying email attachment. If for some reason, you did not receive
those personalized forms, please contact the Business Office.
The following items are required for registration to be complete:
□Signed Tuition Contract* with tuition payment option selected
There are two copies of the tuition contract, please keep the copy that has (parent copy) printed on top for your records. If you are applying for
tuition assistance, include your completed Tuition Assistance Application together with all supporting data in lieu of the signed contract.
□Registration Fee + Post-Dated Checks for Scholarship Fund and Bedek Habayis
For your convenience, you can submit your registration without any checks and the office will automatically include the Registration, Scholarship
Fund and Bedek Habayis fees into your FACTS tuition payments to be divided over your ten month payment schedule.
□Updated or Confirmed Contact & Emergency Information Form*
This form includes the Contact & Emergency Information that is currently on file for your family. Please make sure that all information (including the
emergency contacts) is complete and correct. If all the information is up-to-date, please check "no changes needed." If information is missing or you
would like to make changes, please check off "changes needed" and write the changes directly on the sheet. The Yeshiva recently updated its
student data management software. A careful review of this form will help ensure that your account information in the new system is
accurate.
□Signed Consent Form
□Signed District Textbook Application Request Form
*
(page 3)
This form is what allows YDN to receive textbooks from the district on your son/s behalf. One form needs to be completed PER registered student
in grades P-8. Only the top portion of the form needs to be completed and signed.
□E-Rate Survey
(page 4)
YDN is eligible for certain government funds based on the results of this survey. Please complete and return EVEN if your family does NOT qualify.
Results are kept strictly confidential.
□Medical Forms
– IF REQUIRED - please see the Message from the Nurse's office (page 5)
If you previously submitted some of the required medical forms to the Nurse's Office, you do not need to resubmit those forms together with your
registration.
st
PLEASE NOTE: If you are not able to get updated medical records (if applicable) by May 31 , because you have an appointment scheduled for
over the summer, please include a note with your appointment date together with all other registration items. If all other items are submitted by May
st
31 , you will still be eligible for the REGISTRATION DISCOUNT of $200 PER STUDENT, but unfortunately, an admit card cannot be issued until
any required immunization records are received.
Enjoy Your Summer!
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One form is needed PER student (P-8). Please complete and sign the TOP portion of the form.
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One form is needed PER family.
E-RATE SURVEY
2015-2016 School Year
The results of this survey will be kept strictly confidential. Simply by completing this form, you can enable YDN to
receive government funding to cover certain costs - THANK YOU!
Family Name: ______________________________________________
Street Address: _____________________________________________
City______________________State ___________Zip______________
Circle the number of people in your family
(including all children) on this chart and answer the questions below:
Family Size
Annual
Income
Monthly
Income
Weekly
Income
1
$21,590
$1,800
$416
2
3
4
5
6
7
$29,101
$36,612
$44,123
$51,634
$59,145
$66,656
$2,426
$3,051
$3,677
$4,303
$4,929
$5,555
$560
$705
$849
$993
$1,138
$1,282
8
$74,167
$6,181
$1,427
$7,511
$626
$145
For each
additional family
member add:
1. Is your family's income equal to or less than the amount listed next to the number you circled?
Yes  No 
2. If you answered YES, please list the names of all school age children living in your home, including
the schools they attend:
Name of Child
School
Grade
_
________________________________ ________________________________ ______________
________________________________ ________________________________ ______________
________________________________ ________________________________ ______________
________________________________ ________________________________ ______________
________________________________ ________________________________ ______________
________________________________ ________________________________ ______________
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IMPORTANT MESSAGES FROM THE NURSE’S OFFICE
Dear Parents,
Enclosed you will find all the relevant information needed for a healthy 2015-2016 school year.
Read the information carefully as some information pertains only to certain grades.
IMMUNIZATION REQUIREMENTS
Please check with your health care provider to make sure that your child has all the needed immunizations.
They are listed below.
New Students Entering 1st- 8th grade
Students Entering P1A
Immunization
Polio
Hepatitis B
Diphtheria/Tetanus/Pertussis
Measles/Mumps/Rubella
Varicella (Chickenpox)
Number of Doses
3-4
3
4-5
1
2
Immunization
Polio
Hepatitis B
Diphtheria/Tetanus/Pertussis
Measles/Mumps/Rubella
Varicella (Chickenpox)
TH
Tdap 6-8 grade only
Number of Doses
3
3
4-5
2
1
1
All students entering 6th grade need a Tdap Vaccine when they turn 11 years of age.
HEALTH APPRAISAL/PHYSICAL EXAMS
NY State mandates Health Examinations for the following grades:
•PRE-1A•2nd•4th• 7thand
ALL NEW* STUDENTS (regardless of their grade)
Please send in a completed Health care provider's physical form or attached is a form for your provider to fill out.
The most recent physical form must be dated after 9/1/2014.
*In addition to a health appraisal, all NEW students must also submit a completed a Health History Record Form.
ALLERGIES & MEDICAL INFORMATION
If your son has an allergy (food, insect, latex, etc.) or medical issue, we should know about, please alert both the
nurse and teachers so we can send an emergency care plan for your pediatrician to fill out. This will enable us to
help prevent contact with the allergen and treat any reactions.
MEDICATION
I cannot administer any medication without a signed authorization from your child's Healthcare Provider. This
Includes all over the counter medications, e.g. Tylenol, Motrin, Benadryl and Tums.
For all students, please have your Healthcare provider fill out the "Authorization for Medication," section
on the physical form enclosed, or they can write a prescription for the 2015-2016 school year.
Completing this form before the start of school will prevent any inconveniences or delays if your son
needs medication during the school year. I will let parents know before I give students any medication
Please return the completed documentation to the school together with the rest of your registration forms. If you
have any questions or concerns, call 845-352-7100 ext. 109 or email to nurse@darcheinoam.org
Thank you in advance for your cooperation.
Cara Rogers-Yakal, RN
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YESHIVA DARCHEI NOAM
Health Appraisal/Physical Form
Name:___________________________________________________Grade______________Date of Birth:___________________
IMMUNIZATIONS / HEALTH HISTORY
 No immunizations given today
 Immunization record attached
 Immunizations up-to-date
PPD:
 Positive  Negative  Not done Date: _______
Elevated Lead
 Yes
 No
 Not done Date: _______
Labs: U/A______ Other______________________________________
Significant Medical/Surgical History:  see Attached___________________________________________________________________
Specify current diseases:
ALLERGIES:
Asthma
Seizures
Diabetes:
Type 1
Type 2
Hypertension
Other
LIFE-THREATENING
NON LIFE-THREATENING
Insect_________
Medication______________________ Latex______
Food__________________________________________ Seasonal_______________
Other______________________________
PHYSICAL EXAM
Height_________ Weight________ BMI_________ Percentile
< 5th
5th to 49th
50th to 84th
85th to 94th
95th to 98th
>99th
B/P __________ Pulse _________ Heart__________ Lungs_________
Scoliosis  Negative  Positive_______
 EXAM ENTIRELY NORMAL Tanner: I. II. III. IV. V.
 Specify and abnormality_____________________________
Vision Right 20/___ Left 20/___ with Lenses 
Hearing  Pass 20 db sc both ears or: R_____L____
MEDICATIONS
 Medications (list all):
 None
 Additional medications listed on reverse of form
 if AM dose is missed at home give in school
Name: ____________________________________________________ Dosage/Time: ___________________________________________________
Name: ____________________________________________________ Dosage/Time: ___________________________________________________
I assess this student to be self-directed  Yes  No
Student may self carry and self administer medication  Yes  No
Authorization for Administration of Medication in School including OTC Medication
Parents will be notified prior to administrating medication to students
MEDICATION
DOSE
ROUTE
TIMES TO BE
ADMINISTERED
INDICATIONS
COMMENTS
Tylenol (acetaminophen)
Advil (ibuprofen)
Tums
Benadryl (diphenhydramine HCl)
Recommendation or Restriction for Participation in Physical Education/Sports/Work:
Free from contagions and physically qualified for all activities (phys ed. athletics, playground, work, school)
Recommendation/restrictions___________________________________________________________________________
All information contained herein is valid through the last day of the month for 12 months from the date below
Medical Provider Signature: ____________________________________________________ Date______________________
Provider’s Name/Address: _____________________________________________________
(Stamp Below)
Parent Signature: _____________________________________________________________
Return to: YESHIVA DARCHEI NOAM  257 GRANDVIEW AVENUE  SUFFERN, NY 10901  845.352.7100  F: 845.352.9593
‫בס"ד‬
HEALTH HISTORY RECORD
Please fill out for each NEW student
STUDENT’S NAME______________________________________________________ DATE OF BIRTH_______________
ADDRESS___________________________________________________________________________GRADE____________
HOME TELEPHONE __________________________________________ STUDENT’S BIRTHPLACE_____________________
FATHER’S NAME____________________________________________________ BIRTHPLACE________________________
MOTHER’S NAME___________________________________________________ BIRTHPLACE_________________________
CHILD’S DOCTOR’S NAME____________________________________________TELEPHONE_________________________
CHILD’S DENTIST’S NAME ____________________________________________TELEPHONE_________________________
ORTHODONTIS’S NAME ______________________________________________TELEPHONE_________________________
Has pupil had any of the following illnesses? Please give year.
Chicken pox____________
Rheumatic Fever________
ALLERGIES TO:
Tuberculosis____________
Scarlet Fever___________
Pneumonia______________
Seizure Disorder________
Medications___________________________
Bronchitis_______________
Heart Disease__________
Seasonal _____________________________
Lyme Disease____________
Migraine_______________
Food_________________________________
Mononucleosis___________
Asthma________________
__________________________________
Diabetes_________________ Other__________________________________________________________________
Is there any other phase of the pupil’s health that the school should be aware? i.e. High fevers, serious illnesses heart
murmurs, surgeries, serious injuries or any other medical problems that should concern the school.____________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Has your child ever been hospitalized? _______If yes, when and why_________________________________
Any history of Amblyopia (lazy eye) in the family?
No___Yes___ Relationship to child_________________
Has pupil had a vision exam with an eye doctor?
No___Yes___ Date_______________________________
Does pupil wear glasses?
No___Yes___ When was present lenses received? ____
Has pupil seen an eye doctor for any other
eye condition?
No___Yes___ Describe ___________________________
Does pupil have any speech problems?
No___Yes___ Has there been any speech therapy? ____
Has pupil received any Dental Care?
No___Yes___
Orthodontia (braces)
No___Yes___
Additional information or comments: ___________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Parent/guardian ___________________________________________________________Date__________________________
BREAKFAST ENROLLMENT FORM
Grades 6-8
September 2015 – January 2016
Five Month Enrollment
Full Breakfast Program (Monday – Friday)/ $395 per student
Milk Only for Breakfast (Monday-Friday/ $90 per student
Family name:________________________________________________________
Talmid's First Name
Grade
Please select
Full Breakfast
Milk Only
$395
$90
1.
2.
3.
4.
Total Amount Due:
Please find my check enclosed. Please make checks payable to Yeshiva
Darchei Noam. Unfortunately, post-dated checks cannot be accepted for the
breakfast/milk program.
Please add the amount due to my upcoming FACTS
payment.
Please use my credit card information to
make the payment. (Please note: there is a 2.5%
percent fee for payments made by credit card)
Name on Card:______________________________Card Type:_____________
Card Number:_________________________________________CVV________
Ex. Date:___/___Billing Address:_______________________________________
Parent Signature: _____________________________ Date:____________________
Please return your completed form and full payment to the
Yeshiva Darchei Noam Business Office by Monday, August 24, 2015