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Teen Group
Please verify reCaptcha before submitting the form.
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Parent/Guardian 1 First Name
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Parent 1 Last Name
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Parent 1 Email
Home Phone
Parent 1 Work Phone
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Parent 1 Cellphone
Parent/Guardian 2 First Name
Parent 2 Last Name
Parent 2 Email
Home Phone
Parent 2 Work Phone
Parent 2 Cellphone
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Address line 1
Address line 2 (if needed)
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City/Town
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State
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ZIP
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Is P2 address same as P1 address?
YES (parents/guardians live together
NO- parents do not live together (fill out Parent/Guardians 2's address, below)
Parent/Guardian 2 Address
Address line 2 (if needed)
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City/Town
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State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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ZIP
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Emergency Contact: Full Name
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Relationship
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Cell number
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Student 1 Name (First, Last)
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Hebrew name (ex. David ben Yisrael v'Sarah)
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Lives with?
*
Date of birth
Student's email (if they have one)
Student's cell # (if they have one)
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School name
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Grade in school (as of Sept 2024)
Please Select One
Teen Program
*
Any allergies or medical conditions we should know about (enter N/A if none)
*
Please tell us any other information you feel we should know about (i.e. IEPs, special needs, etc.) (enter N/A if none)
Student 2 Name (First, Last)
Hebrew name (ex. David ben Yisrael v'Sarah)
Lives with?
Date of birth
Student's email (if they have one)
Student's cell # (if they have one)
School name
Grade in school (as of Sept 2024)
Please Select One
Teen Program
Any allergies or medical conditions we should know about (enter N/A if none)
Please tell us any other information you feel we should know about (i.e. IEPs, special needs, etc.) (enter N/A if none)
*
From time to time, photos and videos of our students may be posted on our website, cable TV, or in newspapers. Students' full names are never included with their images. Please let us know if you give your permission for such images to be used
Yes
No
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Is your family a member of B'nai Tikvah?
Yes
No
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Authorization: By clicking here, I/we hereby register my/our child(ren) for the B'nai Tikvah Teen Group
Authorization: By clicking here, I/we hereby register my/our child(ren) for the B'nai Tikvah Teen Group
Sat, July 27 2024 21 Tammuz 5784