Waxman Youth House Registration - TBE

This form is for Temple Beth-El Families, only.

TIGN families should register using the "School Enrollment" feature on ShulCloud. If your family is a member of neither congregation, there is a different form. Click here for more about registration.

Please contact the office if you have any questions.

Parent/Guardian 1

* Parent/Guardian 1 - First Name

* Parent/Guardian 1 - Last Name

* Parent/Guardian 1 - Email

* Parent/Guardian 1 - Mobile Phone

* Is there a second parent/guardian?

Parent/Guardian 2

* Parent/Guardian 2 - First Name

* Parent/Guardian 2 - Last Name

* Parent/Guardian 2 - Email

* Parent/Guardian 2 - Mobile Phone

* Do both parents live at the same address as the student?

* Parent/Guardian 2 - Address

* Parent/Guardian 2 - City

* Parent/Guardian 2 - State

* Parent/Guardian 2 - Zip Code

Parent/Guardian 2 - Home Phone

Student Information

* Address

* City

* State

* Zip

Home Phone

* Photo Waiver

Photo WaiverI give Temple Israel permission to use photos of my child(ren) in its publicity such as in The Voice, on the TIGN website, in local newspapers, etc.

* How many students are you registering for Youth House for the 2023-2024 school year?

Student 1

* Student 1 - First Name

Student 1 - Last Name

Student 1 - Birthdate

* Student 1 - Email Address

* Student 1 - Cell Phone

* Student 1 - Grade

* Student 1 - Does this teen have any allergies, medications, or restrictions?

Student 2

* Student 2 - First Name

Student 2 - Last Name

Student 2 - Birthdate

* Student 2 - Email

* Student 2 - Cell Phone

* Student 2 - Grade

* Student 2 - Does this teen have any allergies, medications, or restrictions?

Student 3

* Student 3 - First Name

Student 3 - Last Name

Student 3 - Birthdate

* Student 3 - Email

* Student 3 - Cell Phone

Student 3 - Grade as of Sept

* Student 3 - Grade

* Does this teen have any allergies, medications, or food restrictions we should be aware of?

Student 4 - First Name

Student 4 - Last Name

Student 4 - Gender

Student 4 - Hebrew Name

Student 4 - Birthdate

Student 4 - Grade as of Sept

Student 4 - IEP

Does he/she have an IEP or special arrangements in Public School?

Student 4 - Allergies

Does this child have any allergies, medications, or food restrictions we should be aware of?

Emergency

In the event that we cannot contact a parent/guardian, we need an emergency contact. Do NOT enter a parent's information in this section.

* Emergency Contact 1 - Name

* Emergency Contact 1 - Phone

Emergency Contact 2 - Name

Emergency Contact 2 - Phone

Donation

The Waxman Youth House Scholarship Fund helps families in need who might not otherwise be able to afford a Youth House education for their children. Any amount is helpful.

* Would you like to contribute?

NoYes

Donation amount:

Total

Thank you so much for completing Waxman Youth House registration for your family! We look forward to a wonderful year!

Sun, May 12 2024 4 Iyyar 5784