Beth El Teen Program Form
Beth El Youth Community programs are highly subsidized by membership dues and annual fundraisers, like the Purim Campaign. We greatly appreciate your formally joining our community!

Please complete all items below. A completed membership form and payment of youth dues are required for participation in all Youth Community events and programs both at Beth El Synagogue Center and off-Site. This includes youth groups, Basketball, It's A Girl Thing, etc.

Please note that if you are currently a Beth El Synagogue Center member, you need not fill out this form. If you need to update your information, please email jvegh@bethelnr.org.

Youth Group Registration
Please mail check to:

Beth El Synagogue Center
c/o Youth Community Membership
1324 North Avenue
New Rochelle, NY 10804

Select Youth Membership *
Pricing is the same for members and non-members at this time.
Required
Teen Information
Please fill out all information below as it pertains to the teen.
First Name *
Your answer
Last Name *
Your answer
Teen Email *
Your answer
Teen Cell Phone Number *
Please include area code (EX: 914-555-0000).
Your answer
Grade as of September 2017 *
School as of September 2017 *
Your answer
Home Phone *
Please include area code (EX: 914-555-0000).
Your answer
Parent 1 Name *
Your answer
Parent 1 Email *
Your answer
Parent 2 Name
Your answer
Parent 2 Email
Your answer
Home Address *
Street
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Date of Birth *
mm/dd/yyyy
Your answer
Medical Information
Please fill out all information below as it pertains to the participant.
Food Allergies
Your answer
Medical Conditions
Your answer
Medications
Your answer
Submit
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