REGISTRATION FORM Registration for 2019/20 is now open for 8th and 9th graders! ► PARTCIPANT INFO First Name Last Name Gender Male Female School Attending Address City State NY Zip Home Phone Cell Phone Email Date of Birth Allergies Synagogue Affiliation ► PARENT INFO Mom First Name Mom Last name Mom Cell Number Mom Email Dad First Name Dad Last name Dad Cell Number Dad Email ►BILLING INFO Cost Scholarship price *$500.00 No one is turned away due to lack of funds. I would like to help sponsor a teen who lacks the funds to participate Amount $36.00 $54.00 $72.00 $150.00 $360.00 Payment Method Visa Master Card American Express Name on Card Card Number Exp. Date CVC Number Address City State Zip Please email confirmation to the following email address ► This page uses 128 bit SSL encryption to keep your data secure.
