Teen Initiative

REGISTER BELOW!

* Student First Name

Middle Name

* Last Name

* Student cell phone number

* Name of school

Grade in 2024-2025

* How many adults are there in your household?

Parent Information

Parent #1

* First Name

* Last Name

* Cell Phone

Home Phone

* Email address

Parent #2

First Name

Last Name

Cell Phone

Home Phone

Medical Information

Allergies to food or medications

* My child uses an EPI-PEN to respond to allergic reactions

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?

YesNo, another synagogueNo, unaffiliated with a synagogue

Synagogue affiliation:

How did you hear about this program?

Tue, May 6 2025 8 Iyyar 5785