Teen Group

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* Parent/Guardian 1 First Name

* Parent 1 Last Name

* Parent 1 Email

Home Phone

Parent 1 Work Phone

* Parent 1 Cellphone

Parent/Guardian 2 First Name

Parent 2 Last Name

Parent 2 Email

Home Phone

Parent 2 Work Phone

Parent 2 Cellphone

* Address line 1

Address line 2 (if needed)

* City/Town

* State

* ZIP

* Is P2 address same as P1 address?

YES (parents/guardians live togetherNO- parents do not live together (fill out Parent/Guardians 2's address, below)

Parent/Guardian 2 Address

Address line 2 (if needed)

* City/Town

* State

* ZIP

* Emergency Contact: Full Name

* Relationship

* Cell number

* Student 1 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 2023)

* 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 2023)

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

YesNo

* Is your family a member of B'nai Tikvah?

YesNo

* 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

Thu, May 2 2024 24 Nisan 5784