Standing up to Antisemitism Registration

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Standing Up to Antisemitism
Registration for Course - Spring 2024

High School Teens, Grades 9-12
$36 per student

*Attendance at all sessions is required in order to receive certification as a Standing Up to Antisemitism Ambassador.*

* Student's Full Name

* Student's Grade as of Sept. 2023

* Student's Date of Birth

* Student's Email

Student's Cell Phone (if applicable)

* Student's Address

* City

* Postal Code

* Parent/Guardian #1 First Name

* Parent/Guardian #1 Last Name

* Parent/Guardian #1 Email

Parent/Guardian #1 Home Phone

* Parent/Guardian #1 Mobile Phone

Parent/Guardian #2 First Name

Parent/Guardian #2 Last Name

Parent/Guardian #2 Email

Parent/Guardian #2 Home Phone

Parent/Guardian #2 Mobile Phone

* Local Non-Parent Emergency Contact Name

* Emergency Contact Phone Number

* Emergency Contact Relationship to Child(ren)

Is the student a member of Marlboro Jewish Center?

Please Select OneYesNo

Which synagogue does the student belong to? (Write N/A for no synagogue affiliation)

Please list any information that we should be aware of involving your child's participation in the course.

* Media Permissions

Please Select OneI give permission for my child(ren)s photograph or video image to be published in any form of media via print or electronicI DO NOT give permission for my child(ren)s photograph or video image to be published in any form of media via print or electronic

PAYMENT

Check here to register for the course ($36 per student)

If you would like to make a donation to the Center to Combat Antisemitism, please list the amount here:

Total Amount:

Tue, May 14 2024 6 Iyyar 5784