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CHAVAYA: Temple Israel Teen Registration Grades 8th-12th 2022-2023

Temple Israel prides itself on the ability to engage post B'nei Mitzvah teens through learning, leadership, social initiatives and acts of Tikkun Olam (repairing the world).

We have a wide array of offerings for our teens and hope they will choose the programs and events that meet their needs.

The Teen Registration can be found below and includes the following options:
-Tuesday evening learning sessions
-Teen Trip to Washington, DC in February. Please note there is an additional fee for the trip.
-Moving Traditions (once a month on Tuesdays).
-Signon, Temple Israel's BBYO (B'nei Brith Youth Organization Chapter.) Please note there are additional fees for events.

-Better Together (An Intergenerational Program that brings together teens and senior citizens in the community. Teens who participate in Better Together can earn community service credit.)

Applications must be completed in one computer session using a desktop computer or laptop. This application is not "user friendly" with PDA devices.

Complete one application per child. Full payment or first installment of a payment plan is required in order to complete registration. Registrations must be submitted on or before Wednesday, August 31st.

Contact Rebecca at relkusferst@tinr.org with questions.

Information About Teen

* Name of Teen (Last, First)

Nickname

* Birthdate (MM/DD/YYYY)

* Gender

Male
Female
Non-Binary

* Primary Address of Child (Address, City, State, Zip)

* Home Phone Number (###-###-####)

* Teen's Cell Phone for Programming Purposes ###-###-####)

* Teen's Email Address

* Teen's Secular Grade as of September 2022

Teen Programming is subsidized by Temple Israel. Please consider paying the actual cost for the Temple. The difference is a tax deductible donation.

A 3% administrative fee will be added if you choose to pay by credit card.

Two Registration Options:

Registration Option #1: Teens have the opportunity to participate in our weekly Tuesday evening program as well as additional engagement opportunities. This option includes 10th grade Confirmation and 12th grade Graduation.

Registration Option #2: Teens who are looking for a more flexible option and can commit to Moving Traditions (our monthly gender separated groups) on Tuesday evenings. If you select this option and also wish to participate in the 10th grade Confirmation and 12th grade Graduation service, you must also select TWO Additional Engagement Opportunities from the list below.

Registration Option #1: Tuesday Evening Learning Sessions (Every Tuesday: Includes dinner, Electives, Core Class & Moving Traditions)

	Click here to select this option and to pay in full	$915.00
	Click here to select payment option over 9 months	$101.67

If you selected Option #1 and wish to participate in additional engagement opportunties, select from the list below.

	Signon (BBYO Chapter)
	Better Together: Intergenerational Program for teens and senior citizens.
	Youth Basketball: Interested teens will receive additional information from the Basketball coordinator.
	Madreecheem: Teen Volunteers in younger Chavaya groups on Tuesday afternoons from 4-6pm.
	Homework Helpers: Teens will serve as Homwork Tutors on Thursday afternoons from 4-6pm. This is a paid position and teens will need to interview with Rebecca.

Registration Option #2: Tuesday Moving Traditions (Once a Month on Tuesday Evening & Includes Dinner) PLUS Choose TWO options from below:

	Click here to select this option and to pay in full	$455.00
	Click here to select this option over 9 months	$50.56

This option is for teens who would like to be part of our Tuesday evening learning program but are unable to commit to attend every week.

Registration Options for Teens Selecting #2 (Choose a minimum of 2 in order to participate in 10th grade Confirmation and 12th grade Graduation service.

	Signon (BBYO Chapter)
	Better Together: Intergenerational Program for teens and senior citizens.
	Youth Basketball: Interested teens will receive additional information from the Basketball coordinator.
	Madreecheem: Teen Volunteers in younger Chavaya groups on Tuesday afternoons from 4-6pm.
	Homework Helpers: Teens will serve as Homwork Tutors on Thursday afternoons from 4-6pm. This is a paid position and teens will need to interview with Rebecca.

Registration Option #3 for 9th-12th Graders: Teen Trip to the Religious Action Center (RAC) in Washington, DC on February 10-13, 2023. Teens and parents will need to attend a prep meeting prior to the trip.

	I would like to participate in the RAC Trip* and will pay in full	$500.00
	I would like to participate in the RAC Trip and will pay a deposit	$250.00

*Cost of trip includes travel to/from Washington, DC., lodging, and meals.

**10th and 12th grades are special years in Chavaya. This year's 10th grade Confirmation service will take place on Thursday, May 25th in the evening. The 12th grade Graduation service will take place on Friday, May 12th in the evening. Costs for these special events will be billed later in the year. Confirmation Celebration: $275.00, Graduation Celebration: $75.00.

Parent Information

* Name of Parent/Guardian 1 (Last, First)

* Parent/Guardian 1 Home Phone Number (###-###-####)

* Parent/Guardian 1 Home Address (Address, City, State, Zip)

* Parent/Guardian 1 Cell Phone Number (###-###-####)

Parent/Guardian 1 Work Number (###-###-####)

* Parent/Guardian 1 Email Address

Name of Parent/Guardian 2 (Last, First)

Parent/Guardian 2 Home Address (Address, City, State, Zip)

Parent/Guardian 2 Home Phone Number (###-###-####)

Parent/Guardian 2 Cell Phone Number (###-###-####)

Parent/Guardian 2 Work Number (###-###-####)

Parent/Guardian 2 Email Address

Name of Parent/Guardian 3 (Last, First)

Parent/Guardian 3 Home Address (Address, City, State, Zip)

Parent/Guardian 3 Home Phone Number (###-###-####)

Parent/Guardian 3 Cell Phone Number (###-###-####)

Parent/Guardian 3 Work Phone Number (###-###-####)

Parent/Guardian 3 Email Address

Teen Engagement Committee: We need Parent Volunteers!

The committee works with Temple Israel staff to help provide teenagers with opportunities to remain involved with Temple Israel and Jewish life. This initiative began last year and we are looking to recruit more parents who are invested in teen engagement.

Click here if you are interested in learning more about the Teen Engagement committee.

Emergency Contact Information if we can't reach a Parent or Guardian

* Name of Emergency Contact (Last, First)

* Emergency Contact Home Phone Number (###-###-####)

* Emergency Contact Cell Phone Number (###-###-####)

* Emergency Contact Relationship to Child

Medical/Learning Information

Please provide any information, such as medical needs, which may be of help to the Director of Education and faculty.

Medications that your teen may need to take during programming.

Allergies (especially food allergies). Please be specific.

Will your teen need to carry an Epi-Pen on them while attending programming?

* Has your teen received the COVID vaccine?

Yes, my teen has received the COVID vaccine.
No, my teen has not received the COVID vaccine.

* Physician's Name (Last, First)

* Physician's Phone Number (###-###-###)

* Name of Insurance Company

* Insurance Company ID

* Policy #

* Insurance Company Phone Number (###-###-####)

Immunization Record & Community Brit (Behavior Contract)

* All registered teens must submit an up-to-date immunization record on file, and the Teen Brit (Behavior Contract) must be signed by parent(s) and teen in order to participate in programming.

I understand that we will need to submit all forms in order for registration to be complete.

Authorizations

The teen listed above has my permission to engage in all Temple Israel of New Rochelle (TINR) Programming and Youth Group activities except as noted below.

In the event that I cannot be reached in an emergency, I hereby give permission to TINR to seek emergency medical treatment and arrange necessary related transportation for my child. I hereby give permission to the physician/health care provider selected by TINR to secure and administer treatment, including hospitalization, for the person named above.

When a TINR event is not on the temple premises, I give permission for my son/daughter to be driven to and from the event by an authorized mode of transportation. I agree to indemnify and hold harmless TINR, their employees, volunteers, and members from any harm which may come to my son/daughter while in transport to or from the event, or during said event.

* I am aware that pictures of my teen may be taken at TINR events and give permission for them to be posted on the TINR website or printed in TINR publications.

Exceptions for Teen

* By checking this box I agree to the above authorization and that the responses are as accurate as possible.

Please make sure the registration form is completed in its entirety and click "register."

Donation to Chavaya

We greatly appreciate your contribution to help defray the costs of our program. Donations are tax deductible.

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

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