Teen JQSA - LGBTQ+ Movie Night
Please fill out the following RSVP form if you plan on attending the Teen JQSA's LGBTQ+ Movie Night event from 7:30pm - 10pm on September 14th, 2019, located at 801 Larrabee St. West Hollywood, CA 90069.

This event is FREE and open to all teens grades 8 - 12.

*PLEASE NOTE: Most of these questions will only need to be answered for your FIRST Teen JQSA event of the year. Since this is a new program year, we ask that all returning teens fill out the entire form including the questions they've answered in the past. Thank you for your time and understanding. :)
First Name *
Your answer
Last Name *
Your answer
Email *
Your answer
Phone Number *
Your answer
Parent/ Guardian Name *
Your answer
Parent/ Guardian Email *
Your answer
What grade are you in? *
With which gender do you identify? *
What are your pronouns? (check all that apply) *
Required
Please check off any Dietary Restrictions you may have: *
Required
How did you find out about this program? (check all that apply) *
Required
What motivated you to attend this program? (check all that apply) *
Required
Do you identify as Jewish? *
Which of the following best describes your family? *
How important is being Jewish in your life? *
On average, how frequently have you participated in Jewish activities in the last 12 months? *
How many total years have you participated in an overnight camp that had Shabbat services and/or a Jewish education program? *
How many total years have you participated in a Jewish Day School? *
How many total years have you participated in a supplementary Jewish school, such as a Hebrew or Sunday school? *
How many total years have you participated in a Jewish Youth Group or Teen Organization? *
Please list any Jewish organizations or youth groups you are involved with:
Your answer
PRIVACY AGREEMENT
To ensure the creation and maintenance of a safe space for all individuals attending Teen JQSA programs, JQ would like to clearly state all privacy and reporting guidelines for all events where minors shall be present.

Ensuring privacy is of the utmost importance for JQ. When possible JQ staff will seek to uphold the privacy of individuals participating in organization programming. When dealing with the privacy of minors, JQ staff will consult with the legal guardian of a minor when appropriate.

We appreciate the need for privacy, both in dealing with people and in keeping secure records. A number of laws govern our programming, and JQ staff will need to contact someone else and possibly report any situations where they have any reasonable suspicion of child abuse, which can include physical, sexual, emotional abuse, and/or neglect; if any member is going to kill himself/herself or someone else; and if any member is under 16 and having sex with someone 21 years or older or if any member is under 14 and having sex with someone 14 years or older.

Should a situation require further consultation or a breach of confidentiality, Teen JQSA staff are required to notify JQ administrators and the JQ Program Director. The situation will then be brought to the attention of the appropriate legal guardians.
Please check the box below to indicate that you have read and understand the privacy and reporting practices of JQ. *
Required
Thank you and we'll see you soon!
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