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Teen Initiative
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REGISTER BELOW!
*
Student First Name
Middle Name
*
Last Name
*
Student cell phone number
*
Name of school
Grade in 2023-2024
Contact Information
*
How many adults are there in your household?
Please Select One
One
Two
Parent Information
Parent #1
*
First Name
*
Last Name
*
Cell Phone
Home Phone
*
Email address
Parent #2
First Name
Last Name
Cell Phone
Home Phone
Email
Medical Information
Allergies to food or medications
*
My child uses an EPI-PEN to respond to allergic reactions
Please Select One
Yes
No
Medications
* If your teen needs to take medications during this session, please inform Anne Kalis at eitzeducator@gmail.com.
Any other information you want us to know?
Are you a member of Congregation Eitz Chayim?
Yes
No, another synagogue
No, unaffiliated with a synagogue
Synagogue affiliation:
How did you hear about this program?
Sat, July 27 2024 21 Tammuz 5784