Please fill out this information to register for Jewish Teens Talking to Jewish Teens
Semester: Summer 2020 Course Number: TLSU20B Course Section: 1

Although Hebrew College doesn’t require that you share your birthdate, we’ve found that including your birthdate helps us to avoid creating duplicate student records in our database

Student First NameRequired

Student Middle NameRequired

Student Last NameRequired

Student Email AddressRequired

Date of BirthRequired

AddressRequired

Address 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

Home NumberRequired Home Number Area Code Home Number Exchange Home Number Number Home Number Extension  Ext: 

Student Mobile Number (if none, please list best phone number to reach the student)Required Student Mobile Number (if none, please list best phone number to reach the student) Area Code Student Mobile Number (if none, please list best phone number to reach the student) Exchange Student Mobile Number (if none, please list best phone number to reach the student) Number Student Mobile Number (if none, please list best phone number to reach the student) Extension  Ext: 

Parent RelationshipRequired -- choose one -- Aunt/Uncle of Child of 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 First NameRequired

Middle NameRequired

Parent Last NameRequired

Parent EmailRequired

AddressRequired

Address 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

ZipRequired Zip Extension

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

Emergency First NameRequired

Emergency Last NameRequired

Emergency US PhoneRequired Emergency US Phone Area Code Emergency US Phone Exchange Emergency US Phone Number Emergency US Phone Extension  Ext: 

Emergency RelationshipRequired -- choose one -- Guardian Parent Wife of

Program OptionRequired -- choose one -- Prozdor Full-Year Prozdor Half-Year

Current Academic Grade (as of the upcoming September 1)*Required -- choose one -- Grade 10 Grade 11 Grade 12 Grade 6 Grade 7 Grade 8 Grade 9

Preferred NameRequired

How did you hear about Hebrew College?Required -- select one --Advertisement (online) Hebrew College Email Hebrew College Website Jewish community Mailing Social Media Synagogue / Temple Word of Mouth

My Pronouns (OPTIONAL: Hebrew College faculty and staff would like to utilize your pronouns.)Required -- select one --He/him/his They/them/their She/her/hers Other preference

Synagogue, minyan, or other Jewish community affiliation(s), if anyRequired

Are you planning to take Prozdor Hebrew?Required -- select one --Yes, I am taking Hebrew No

IF "Other", Please specifyRequired

Are you interested in applying for financial aid?Required -- select one --Yes No

If yes, please describe Accessibility NeedsRequired

I understand that my picture may be taken during the course of this program, and I agree to its use on the website or in other promotional materials.Required -- select one --Yes, I agree my photo may be taken/used No

Learning Differences (IEP, 504)*:Required -- select one --Yes No

Parent Date of BirthRequired

Current Age (as of the upcoming September 1)*:Required

Has the student attended a Jewish Day or overnight camp? If yes, where? Indicate N/A if not applicable.Required

Tell us about your previous Jewish Education (e.g. Day School, Hebrew school, learning programs, etc). Indicate N/A if not applicable.Required

Previous experience with programs at Hebrew CollegeRequired

To be answered by a parent or guardian: By typing my name, I agree to the terms above.Required

I hereby enroll my child in Hebrew College Teen Learning programs for the academic year 2020–2021.

1. I agree to pay the full tuition and fees, as applicable, in accordance with the payment plan chosen and the policies listed above.

I understand that once I sign this agreement, I am liable for the 25% tuition that is considered forfeit should a student withdraw.

2. I hereby give permission to my child to participate in all programs, activities and events and release Hebrew College and its representatives from all liability arising out of my child’s

participation in such activity.

3. I agree that in case of an emergency, Hebrew College may make all reasonable efforts to secure and administer treatment, including hospitalizations for the student. All financially

responsible parties must electronically sign their name below. *