2022-2023 Teen Collab Registration Form - Form

Our teen program is expanding and has so much to offer - we hope that our teens will find at least one component that speaks to them and will participate. If there's something that feels missing, please reach out, we'd love to hear from you!

Section A: Family Contact Information

* First Name (Primary)

* Last Name (Primary)

Preferred Pronouns (he/him, she/her, they/them, other)

* Email (Primary)

* Phone (Primary)

* Relationship to Teen(s) (Primary)

* Street Address (Primary)

Street Address Line 2 (Primary)

* City (Primary)

* State (Primary)

* ZIP (Primary)

* Is there a secondary contact?

Please Select OneNoYes, at the same address as the primary contactYes, but at a different address than the primary contactIf 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

* First Name (Secondary)

* Last Name (Secondary)

Preferred Pronouns

* 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 Name

* Emergency Contact Phone

* Emergency Contact Relationship

Section B: Teen Enrollment Information

* How many teens are being enrolled in grades 8-12 for the 2022-2023 year?

Teen 1 Information

* Teen 1 First Name

* Teen 1 Last Name

* Preferred Pronouns (he/him, she/her, they/them, other)

* Teen 1 Birthdate

Teen 1 Nickname (if applicable)

* Teen 1 Secular School Name

Teen 1 Email

Information will not be shared publicly. Parents will be copied
on all communication to students.

Teen 1 Phone

Information will not be shared publicly.

* Teen 1 Program Selection

Teen Collab Module 1 (10/26, 11/2, 11/9, 11/30, 12/7, 12/14)Teen Collab Module 2 (1/5, 1/12, 1/19, 1/26, 2/2, 2/9)Teen Collab Module 3 (3/5, 3/12, 3/19, 3/26, 4/16, 4/23, 4/30)All three modules of the Teen Collaborative

In which courses would you like to enroll? (Please only select one course from each module)

* Teen 1 Learning Needs

Are there any important educational needs that would help us support your teen's learning? If you prefer, please feel free to reach out to our Education Director, Adam Bender via email.

Teen 1 Additional Information

Is there anything else you would like your child’s teacher to know?

* Teen 1 Allergies or Medications

Please Select OneNoYesDoes your teen have allergies or medications we need to know about?

Teen 1 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Teen 2 Information

* Teen 2 First Name

* Teen 2 Last Name

* Preferred Pronouns (he/him, she/her, they/them, other)

* Teen 2 Birthdate

Teen 2 Nickname (if applicable)

* Teen 2 Secular School Name

Teen 2 Email (if applicable)

Information will not be shared publicly. Parents will be copied
on all communication to teens.

Teen 2 Phone (if applicable)

Information will not be shared publicly.

* Teen 2 Program Selection

In which courses would you like to enroll? (Please only select one course from each module)

* Teen 2 Learning Needs

Are there any important educational needs that would help us support your teen's learning? If you prefer, please feel free to reach out to our Education Director, Adam Bender via email.

Student 2 Additional Information

Is there anything else you would like your child’s teacher to know?

* Student 2 Allergies or Medications

Please Select OneNoYesDoes 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 Information

* Teen 3 First Name

* Teen 3 Last Name

* Preferred Pronouns (he/him, she/her, they/them, other)

* Teen 3 Birthdate

Teen 3 Nickname (if applicable)

* Teen 3 Program Selection

Teen Collab Module 1 (10/26, 11/2, 11/9, 11/30, 12/7, 12/14)Teen Collab Module 2 (1/5, 1/12, 1/19, 1/26, 2/2, 2/9)Teen Collab Module 3 (3/5, 3/12, 3/19, 3/26, 4/16, 4/23, 4/30)All Teen Collaborative

In which courses would you like to enroll? (Please only select one course from each module)

* Teen 3 Secular School Name

Teen 3 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to teens.

Teen 3 Phone (if applicable)

Information will not be shared publicly.

* Student 3 Learning Needs

Are there any important educational needs that would help us support your teen's learning? If you prefer, please feel free to reach out to our Education Director, Adam Bender via email.

Teen 3 Additional Information

Is there anything else you would like your teen's teacher to know?

* Student 3 Allergies or Medications

Please Select OneNoYesDoes your teen have allergies or medications we need to know about?

Teen 3 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Section C: Release Forms

I hereby authorize the Administrator, or person designated by the Administrator, to obtain emergency medical care for my teen(s) in the event such care is indicated. I give my permission for my teen(s) to receive emergency medical care by any nurse, doctor, paramedic or member of a medical staff of a hospital licensed by the State of New York. I understand that every effort will be made to notify a parent/guardian prior to treatment.

I certify that my teen(s) is(are) in good physical health and up to date on vaccinations.

* Medical Release: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

Media Release

* Please indicate where we have permission to share your teen(s)' photo:

Please Select OneI give permission for my teen(s)' image to be used in emails, social media, etc.I do not grant permission for my teen(s)' image to be used.

Section F: Payment Information

* Do you require financial aid?

Please Select OneNoYesThere are many impediments to Jewish education but finances should never be one.
We ask that every family commits to some financial contribution, however we are very happy to discuss financial aid options for any dues paying family that may require tuition assistance.
If you select yes, you will discuss your payment ability in a confidential meeting with the PJC Treasurer.
Please contact Mitch Cepler at Treasurer@thepjc.org.

Financial Aid Follow-up: I understand and will contact the PJC Treasurer

Total Amount