Form Properties
Form is Active (1 or 0)
The Teen Registration Form is not currently active. Please contact the Department of Lifelong Learning at
school@emanuelnyc.org
or 212-507-9546 if you have any questions.
Your form has already been submitted. Please contact the Department of Lifelong Learning at
school@emanuelnyc.org
or 212-507-9546 if you have any questions or concerns.
Department of Lifelong Learning
Teen Registration Form 5784
Family Information
Email Address
Family Name
Street Address
City
State
Postal Code
Country
How is your family currently affiliated with Temple Emanu-El?
Please select...
Member Family
Non-member Family
Not Affiliated
Teen Information
Teen First Name
Teen Last Name
Teen Gender
Please select...
Male
Female
Other
Teen Pronouns Used
Teen Date of Birth
Teen Email
Teen Mobile Phone
Teen B'nei Mitzvah Date (if applicable)
Teen Secular School
Teen Secular School Grade
Please select...
PreK
K
1
2
3
4
5
6
7
8
9
10
11
12
Graduate
Teen Camp Attending
Teen Shirt Size
Additional Information
Does your teen carry an Epi-pen?
Please select...
Yes
No
Parent / Guardian 1 Information
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Parent/Guardian 1 Phone
Parent/Guardian 1 Email
Parent/Guardian 1 Relationship to Teen
Parent / Guardian 2 Information
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Phone
Parent/Guardian 2 Email
Parent/Guardian 2 Relationship to Teen
Emergency Contact 1 Information
Use Parent/Guardian 1 as Emergency Contact 1
Emergency Contact 1 Name
Emergency Contact 1 Phone
Emergency Contact 1 Relationship to Teen
Emergency Contact 2 Information
Use Parent/Guardian 2 as Emergency Contact 2
Emergency Contact 2 Name
Emergency Contact 2 Phone
Emergency Contact 2 Relationship to Teen
Program Interest
Please select the programs your teen is interested in
A-TEEM (Sunday 9:00am-12:00pm)
A-TEEM (Monday 4:00pm-6:00pm)
Calling Generations
Immersive Experience: Arizona 8th-9th Grades
Immersive Experience: Madrid 10th-12th Grades
Immersive Experience: L'Taken 9th-12th Grades
Leadership Enrichment Training
Teen Philanthropic Council
Volunteer Opportunities
Teen High Holy Day Worship: Rosh Hashanah
Teen High Holy Day Worship Yom Kippur
Teen Shabbat March 2025
Card Details
Card Type
Please select...
Visa
Mastercard
Discover
American Express
Cardholder First Name
Cardholder Last Name
Card Number
Secure Code / CVV
Expiration Month
MM
Expiration Year
YYYY
Billing Details
Street
City
State
Postal Code
Country
Order Settings
Payment Amount
Chargent Created Fields