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Youth Education Registration
Please verify reCaptcha before submitting the form.
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Is your family new to our school?
Please Select One
No
Yes
Family Contact Information
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First Name (Primary)
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Last Name (Primary)
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Email (Primary)
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Phone (Primary)
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Relationship to Student(s) (Primary)
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Street Address (Primary)
Street Address Line 2 (Primary)
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City (Primary)
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State (Primary)
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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ZIP (Primary)
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Is there a secondary contact?
Please Select One
No
Yes, at the same address as the primary contact
Yes, but at a different address than the primary contact
If there is a secondary contact, all emails and mailings will go to both contacts. In case of urgent need, the primary contact will be notified first
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First Name (Secondary)
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Last Name (Secondary)
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Email (Secondary)
*
Phone (Secondary)
*
Relationship to Student(s) (Secondary)
*
Street Address (Secondary)
Street Address Line 2 (Secondary)
*
City (Secondary)
*
State (Secondary)
*
ZIP (Secondary)
Emergency Contact
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Emergency Contact Name
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Emergency Contact Phone
*
Emergency Contact Relationship
Student EnrollmentĀ Information
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Student 1 First Name
*
Student 1 Last Name
*
Student 1 Birthdate
*
Student 1 Hebrew Name
*
Student 1 Secular School Name
Student 1 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.
Student 1 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.
*
Student 1 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Student 1 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.
*
Student 2 First Name
*
Student 2 Last Name
*
Student 2 Birthdate
*
Student 2 Hebrew Name
*
Student 2 Secular School Name
Student 2 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.
Student 2 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.
*
Student 2 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Student 2 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.
*
Student 3 First Name
*
Student 3 Last Name
*
Student 3 Birthdate
*
Student 3 Hebrew Name
*
Student 3 Secular School Name
Student 3 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.
Student 3 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.
*
Student 3 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Student 3 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.
*
Student 4 First Name
*
Student 4 Last Name
*
Student 4 Birthdate
*
Student 4 Hebrew Name
*
Student 4 Secular School Name
Student 4 Email (if applicable)
Information will not be shared publicly. Parents will be copied on all communication to students.
Student 4 Phone (if applicable)
Information will not be shared publicly. Students will not be contacted independently from parents.
*
Student 4 Allergies or Medications
Please Select One
No
Yes
Does your child have allergies or medications we need to know about?
Student 4 Allergy/Medication Details
Please describe allergies and medications with dosage and timing.
Wed, December 4 2024 3 Kislev 5785