Please fill out this information to register for Teen Beit Midrash 2024-25: Online
Semester: Teen Learning 24-25 Full Year Course Number: TBM25OLF Course Section: 1

Welcome to Teen Beit Midrash! Welcome back to returning students and welcome to new students. We are excited that you are joining our beit midrash community. Each year our learning takes us in new directions and on new adventures. We look forward to learning with you!

First NameRequired

Middle NameRequired

Last NameRequired

Student Email AddressRequired

Date of BirthRequired

PronounRequired -- choose one -- Any pronoun can be used He/him/his Other preference She/her/hers They/them/their

CountryRequired -- choose one -- UNITED STATES CANADA AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIGUA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA BOTSWANA BRAZIL BRUNEI BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CAPE VERDE CENTRAL AFRICAN REPUBLIC CEYLON CHAD CHILE CHINA COLOMBIA COMOROS CONGO COSTA RICA COTE D"LVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FIJI FINLAND FRANCE FRENCH ANTILLES FRENCH GUIANA GABON GAMBIA GEORGIA GERMANY GHANA GREECE GRENADA GUADELOUPE GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE HONDURAS HONG KONG HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY IVORY COAST JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA KUWAIT KYRGSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW ZEALAND NICARAGUA NIGER NIGERIA NORTH KOREA NORTHERN IRELAND NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PRINCIPE QATAR REPUBLIC OF CHINA ROMANIA RUSSIA RWANDA SAN MARINO SAO TOME SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEON SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH KOREA SOUTH-WEST AFRICA SPAIN SRI LANKA ST. KITTS ST. LUCIA ST. NEVIS ST. VINCENT SUDAN SURINAME SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKSTAN TANZANIA THAILAND THE GRENADINES TOBAGO TOGO TONGA TRINIDAD TUNISIA TURKEY TURKMENISTAN TUVALU UAE UGANDA UKRAINE UNITED KINGDOM UPPER VOLTA URUGUAY UZBEKISTAN VANUATU VATICAN CITY VENEZUELA VIETNAM WALES WEST AFRICA West Indies WESTERN SAMOA YEMEN ZAIRE ZAMBIA ZIMBABWE

Street 1Required

Street 2Required

CityRequired

StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS 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 VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip CodeRequired Zip Code Extension

ProvinceRequired

Postal CodeRequired

Mobile PhoneRequired Mobile Phone Area Code Mobile Phone Exchange Mobile Phone Number Mobile Phone Extension  Ext: 

International Cell PhoneRequired International Cell Phone Extension  Ext: 

Parent\Guardian 1 Relationship (To clarify, the “Relationship” you select here will describe the “Parent/Guardian” listed above. Most Teen Learning students select “Parent of” here.)Required -- choose one -- Aunt/Uncle of Child of Dignity Project Fellow Dignity Project Mentor Emergency Contact Of Graduate Leadrshp Family Class Grandparent of Guardian of Hebrew College Arts Committee JTFGB Advisory Miller Center Advisory Parent of Rabbi 1 of Spouse of Stepchild of Stepparent of Student of Surviving Spouse of

Parent / Guardian 1 First NameRequired

Parent / Guardian 1 Last NameRequired

Parent / Guardian 1 EmailRequired

Parent / Guardian 1 AddressRequired

Parent / Guardian 1 Address 2Required

Parent / Guardian 1 CityRequired

Parent / Guardian 1 StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS 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 VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Parent / Guardian 1 ZipRequired Parent / Guardian 1 Zip Extension

Parent / Guardian 1 Mobile PhoneRequired Parent / Guardian 1 Mobile Phone Area Code Parent / Guardian 1 Mobile Phone Exchange Parent 1 US Phone Number Parent / Guardian 1 Mobile Phone Extension  Ext: 

Parent / Guardian 2 RelationshipRequired -- choose one -- Aunt/Uncle of Child of Dignity Project Fellow Dignity Project Mentor Emergency Contact Of Graduate Leadrshp Family Class Grandparent of Guardian of Hebrew College Arts Committee JTFGB Advisory Miller Center Advisory Parent of Rabbi 1 of Spouse of Stepchild of Stepparent of Student of Surviving Spouse of

Parent / Guardian 2 First NameRequired

Parent / Guardian 2 Last NameRequired

Parent / Guardian 2 emailRequired

Parent / Guardian 2 StreetRequired

Parent / Guardian 2 Street 2Required

Parent / Guardian 2 CityRequired

Parent / Guardian 2 StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS 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 VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Parent / Guardian 2 ZipRequired Parent / Guardian 2 Zip Extension

Parent / Guardian 2 Mobile PhoneRequired Parent / Guardian 2 Mobile Phone Area Code Parent / Guardian 2 Mobile Phone Exchange Parent / Guardian 2 Mobile Phone Number Parent / Guardian 2 Mobile Phone Extension  Ext: 

Emergency Contact First NameRequired

Emergency Contact Last NameRequired

Emergency Contact Email AddressRequired

Emergency Contact Cell Phone NumberRequired Emergency Contact Cell Phone Number Area Code Emergency Contact Cell Phone Number Exchange Emergency US Phone Number Emergency Contact Cell Phone Number Extension  Ext: 

Emergency Contact - Relationship to StudentRequired -- choose one -- Guardian Parent Wife of

School (AS OF FALL 2024)Required

Does your teen have any dietary restrictions, food allergies, and/or environmental allergies? If yes, please describe.Required

What other information would you like to share?Required

Directory ReleaseRequired -- select one --TBM may share my name, telephone, and email with other TBM families. TBM may NOT share my name, telephone, and email with other TBM families.

Grade as of Sept 1Required -- select one --8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

Hebrew birthday, if knownRequired

By typing my name below, I give permission for my child to participate in Hebrew College’s Teen Beit Midrash programming.

By typing my name below, I promise to support my child's participation in meetings, activities, and all aspects of the program. (Please use full name for e-signature.)Required

(Optional) Parent / Guardian 1 PronounsRequired -- select one --She/her/hers He/him/his They/them/their Other preference

IF "Other", Please specifyRequired

PHOTO / AUDIO / VIDEO / WEBSITE RELEASE:Required -- select one --I DO NOT give my permission for images/audio of my child to be used for HC promotional purposes. I give permission for images/audio of my child to be used for HC publicity and promotional purposes.

(Optional) Parent / Guardian 2 PronounsRequired -- select one --They/Them/Theirs She/her/hers He/him/his Other

If "Other", please specify.Required

Please list any other Jewish organizations or activities in which you are involved (youth group, camp, volunteering, fellowships, etc)Required

What draws you most to Teen Beit Midrash? What are your goals for Jewish Learning at Teen Beit Midrash this year?Required

Please tell us about your Jewish education background.Required

How did you learn about Teen Beit Midrash? *If you heard about TBM from a current or past participant, please include their name(s).Required

Is there anything else we should know about your teen as a learner (e.g. IEP, medical conditions, accommodations) to help them thrive at TBM?Required

Do you currently belong to a synagogue? If yes, which one? * Please list the synagogue name and specific city.Required

Are you interested in joining Teen Beit Midrash in-person (Tuesday evenings) or online (Wednesday evenings)?Required -- select one --In Person Online

How does your teen describe their Jewish affiliation?Required

Please describe any health conditions or medical concerns for your teen.Required