Teen Program Registration Home > Jewish Journeys > Youth Education and Programs > Teen Programs > Teen Program Registration Company Teen #1 Information First Name * Name Teen Prefers to be Called * Last Name * Gender * Female Male Date of Birth * e.g. 12/1/1990 Age * 13 14 15 16 17 18 19 Enroll In Kadima (8th) Confirmation (9th/10th) Wilderness Leadership (10th/11th/12th) Can select one above Enroll In checkbox Madrichim (8th-12th Tequires application - see Education Director) NFTY (8th-12th) Can select either, both, or none Secular School Grade as of September 1 Teen Cell Teen E-mail Address Does your teen have special medical or learning needs? Food allergies? We want your teen to be safe and have the best learning experience possible. Knowing his/her special needs will help us make that happen. Medical Issues or Needs? * Yes No Learning Needs / Conditions? * Yes No Food Restrictions or Life Threatening Allergies? * Yes No Media Release Throughout the school year, students may be highlighted in efforts to promote CBHT Religious School activities and achievements. For example, students may be featured in materials to train teachers and/or increase public awareness of our school through newspapers, radio, TV, the web, DVDs, displays, brochures and other types of media, including social media. As the parent or guardian, I hereby give CBHT and its employees, representatives, and authorized media organizations permission to print, photograph, and record my child for use in audio, video, film, or any other electronic, digital and printed media. This is with the understanding that neither CBHT nor its representations will reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child’s participation. I further release and relieve CBHT, its Board of Trustees, employees and other representatives from any liabilities, known or unknown, arising out of the use of this material. Teen 1 Media Certify * I certify that I have read the Media Consent and Release liability statement and fully understand its terms and conditions. Media Release * I Grant permission INCLUDING the use if my teens name I Grant permission but NOT INCLUDING the use if my teens name I DO NOT grant permission Emergency Medical Release I hereby give my consent for Congregation Beth HaTephila staff to make available to my teen professional emergency medical care if such care is indicated. It is my understanding that a conscientious effort will be made to contact me before such action is taken. It is further understood that in the event that this is not possible, I give my permission for my teen to receive proper medical care by any doctor, nurse, paramedic or member of a medical staff of a hospital licensed in the State of North Carolina. Medical Release * I Give my consent I DO NOT give my consent Register a Second Teen? * Yes No If the page doesn't proceed to the next page, it is likely a required field is missing. Scroll up and check all fields with a red *.Parent/Guardian #1 Information First Name * Last Name * Mailing Address * Email * Upon submisstion, a copy of the Registration data is sent to this email address. Cell Phone * Enter all 0s if no cell phone Home Phone * Enter all 0's if no home phone Parent/Guardian #2 Information First Name Last name Mailing Address Email Cell Phone Home Phone or enter all 0's Emergency Contact Information Other than Parent or Guardian listed above First Name * Last Name * Best Phone * Enter all 0s if no phone Alternate Phone Form data is reset upon submission. A copy of the data is sent to Parent/Guardian #1's email.If the page doesn't submit, it is likely a required field is missing or you have entered an invalid email address. Scroll up and check all fields with a red *.