Project PB&J Registration
Community Service Opportunity
12:00 - 2:00 PM
Westside JCC (5870 W. Olympic Boulevard)
On which date or dates will you be attending?
Teen Information
Name
Your answer
Birthdate
MM
/
DD
/
YYYY
Cell Phone (if teen does not have a cell phone, leave blank)
Your answer
Email Address (if teen does not have an email address, leave blank)
Your answer
School
Your answer
Special Needs/Allergies/Medical Issues
Your answer
Parent/ Legal Guardian Information
Primary Contact Is
Teen Lives With
Parent 1 Name
Your answer
Parent 1 Cell Phone
Your answer
Parent 1 Home Phone
Your answer
Parent 1 Email Address
Your answer
Parent 2 Name
Your answer
Parent 2 Cell Phone
Your answer
Parent 2 Home Phone
Your answer
Parent 2 Email Address
Your answer
Emergency Contact Information
Emergency Contact (Other than Legal Guardian)
Your answer
Emergency Contact Phone
Your answer
Relationship
Your answer
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