Register For Urban Shtetl Program 2018-2019
Parent Info
Parent 1 First Name *
Your answer
Parent 1 Last Name *
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Parent 1 Address *
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Parent 1 Email *
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Parent 1 Phone *
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Parent 2 First Name
Your answer
Parent 2 Last Name
Your answer
Parent 2 Address
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Parent 2 Email
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Parent 2 Phone
Your answer
Child Info
Child 1 First Name *
Your answer
Child 1 Last Name *
Your answer
Child 1 Date of Birth *
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YYYY
Child 1 Age *
Your answer
Child 1 Grade *
Your answer
Child 2 First Name
Your answer
Child 2 Last Name
Your answer
Child 2 Date of Birth
MM
/
DD
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YYYY
Child 2 Age
Your answer
Child 2 Grade
Your answer
Child 3 First Name
Your answer
Child 3 Last Name
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Child 3 Date of Birth
MM
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DD
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YYYY
Child 3 Age
Your answer
Child 3 Grade
Your answer
Additional Children - please add all info:
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Interests
What most interests you about being part of the urban shtetl program?
Your answer
Forming Havurah/Tribes - In order to establish the different Tribes of our Shtetl (Groups of 4-6 Families) please tell us which is most important to you in forming your havurah group?(check boxes)
If you are already in an Urban Shtetl Havurah, or if you already have an idea of who you’d like to be in your tribe please list their names below. Don’t worry, if you don’t, we will match you up with other great families.
Your answer
Gathering community resources. What are you or your family awesome at?
Your answer
Do you have any skills or talents that you could offer, teach, or lead? What are they?
Your answer
Payment (for entire family)
*Register by Sept. 21 and save $100.
Program Fee up to 3rd grade: $500 by Sept. 21
Program Fee including Tsofeem (3rd-5th grade program) : $600 by Sept. 21
ADD $100 after September 21, 2018

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