TLC Registration

Teen 1
If you have questions about this form, please email Director of Experiential Learning for Children and Teens Loen Amer at youth@bettorah.org.
Name*
First Prefered name Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Teen Email
Do NOT enter a parent email.
Teen Cell Phone
Do NOT enter a parent cell phone. Leave blank if teen does not have a cell phone.
Teen Pronouns
Examples: he/him/his, she/her/hers, and they/them/their
Middle/High School*
High School Graduation Year*
Dietary Restrictions - Teen 1*
Please select all that apply. If your dietary needs change, please let us know.
- Vegetarian
- Vegan
- Gluten-free
- Lactose intolerant
- Allergic to tree-nuts
- Allergic to peanuts
- Allergic to other foods (please specify below)
- Will happily eat whatever food Bet Torah provides
Food Allergies
Please list any non-food allergies, including pets and medication.
Is there anything about this teen you would like us to know?
Examples might include learning style or anything else you think will help us make this a welcoming and safe space.
Are there any special medical conditions, concerns, or limitations to this teen's participation in TLC?
We ask so we can maximize teens' experiences in our program. All information will be kept confidential.
Teen Code of Conduct*
We ask that the teen read our Code of Conduct and initial below to signify agreement.

Teens are expected to follow the Code so we can all enjoy a healthy and safe environment.
Teen 1 - Program Selection
TLC programs in 2020-21 will continue to gather regardless of whether we are meeting in person or remotely.

Helpful Links: Program Overview | Youth Calendar | Tuition | Contact Us
TLC Program Selection - Teen 1
- Better Together - $60
- Drash with the Rabbi: Next Steps - $200
- Leadership Training Cohort - No fee
- Nosh and Drash - $500
- Rosh Hodesh / Shevet, powered by Moving Traditions - $200
- NEW! Jewish Learning Fellowship - $125
Madrichim applications were due on July 15.
Does your family belong to Bet Torah?*
- Yes
- No
Teens who are not congregants can participate in most TLC programs as long as there is sufficient room for all the members of the congregation who would like to participate.

Tuition rates will be higher. Please consider your subtotal approximate for now.
Tuition Total - Teen 1
Price: $0.00
We value your family’s involvement in Bet Torah and TLC. If you are experiencing financial difficulties or would like to make an alternative payment plan, Executive Director Seth Young will be able to assist you.

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Are you registering a second teen for TLC?*
- Yes
- No

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Are you registering a third child for TLC?
- Yes
- No

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Family Contact Information
Teen(s) Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Prefered Email for Parent Communication*
Parent 1
Name*
First Last
Email*
Cell Phone*
Work Phone
Parent 2
Name
First Last
Email
Cell Phone
Work Phone
Additional Guardianship Information
Is there anything else you would like us to know regarding your child's (or children's) living arrangement? All information will remain confidential.

Please include any other relevant mailing address.
Emergency Contact Information
Do not list parents/guardians listed above. Please list other emergency contacts.
Emergency Contact 1*
First Last
Relationship*
Cell Phone*
Home Phone
Emergency Contact 2
First Last
Relationship
Cell Phone
Home Phone
Medical Consents
I agree that if my child should need any medical attention, Bet Torah is authorized to provide and arrange for treatment and I will be responsible for any costs associated with the treatment.*
I understand that Bet Torah will make every reasonable attempt to reach me or anyone listed above as my emergency contact before using this authorization.*
Vaccinations and Immunizations
All children I have registered above meet all New York State vaccination requirements to be admitted to public, private or parochial school for the 2020-21 school year.*
- Yes
- No
Is there anything you would like to add regarding immunizations?
General Consents
Photo Release*
I understand Bet Torah and its representatives might use photographs of my child in/on the synagogue newsletter, website, social media, including the internet and bulletin boards and in local media. Photos may also be shared with our partner organizations (including but not limited to Mount Kisco Interfaith Food Pantry, Moving Traditions, USY, J-Teen) for their use in similar media.
- Yes
Travel and Trips*
I grant permission for my child to participate in activities and trips (including but not limited to Midnight Run, trips to NYC, programs at private homes, programs at other congregations, etc.).
- Yes
I confirm that the above information if accurate, that the guidelines and procedures of Bet Torah will be adhered to and that I understand it is my responsibility to keep the above information current.*
Is there anything you would like to add regarding consents?

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Your Itemized Tuition
Teen 1
Teen 2
Teen 3
Total
Total Due by Check
Please make your payment to "Bet Torah" and indicate "TLC Tuition 2020" in the note section. Send to:

Bet Torah Synagogue
60 Smith Ave, Mt Kisco, NY 10549
Thank you for your prompt payment of tuition. Registration is not complete until we receive your check.

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TLC Registration

2020-2021 TLC Registration

Step 1 of 7 - Welcome

Teen 1

Teen 1 - Program Selection

Teen 2

Teen 2 - Program Selection

Teen 3

Teen 3 - Program Selection

Family Contact Information

Parent 1

Parent 2

Emergency Contact Information

Medical Consents

Vaccinations and Immunizations

General Consents

Your Itemized Tuition

Total

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