Teen Program Registration

Child #1 Information

e.g. 12/1/1990
Can select one above
Can select either, both, or none
as of September 1

Does your child have special medical or learning needs? Food allergies?

We want your child to be safe and have the best learning experience possible. Knowing his/her special needs will help us make that happen.

Media Release

I grant Congregation Beth HaTephila permission to use any photographs and/or voice/video recordings of my child taken at school or during Religious School/Temple activities, both in print and online. I agree that neither I, nor my child, will receive compensation for the use of any image.

Emergency Medical Release

I hereby give my consent for Congregation Beth HaTephila staff to make available to my child 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 child 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.

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An Engaging Reform Congregation in the Blue Ridge Mountains