Registration

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Which region and chapter are you applying for?*

Teen Information

Teen Name*

First Last

Grade in Fall 2026*

Which school will you attend in Fall 2026?*

Birthday*

Gender*

Teen Email*

Teen Phone Number*

T-Shirt Size (adult sizes)*

Program Cost*

$499: Program Membership

All sales are final. No refund issued after registration.

Would you like to add a 2nd Teen to this registration form?

Yes

Teen 2 Information

Teen 2 Name*

First Last

Grade in Fall 2026 (Teen 2)*

Which school will you attend in Fall 2026? (Teen 2)*

Teen 2 Birthday*

Teen 2 Gender*

Teen 2 Email*

Teen 2 Phone Number*

Teen 2 T-Shirt Size (adult sizes)*

Program Cost (Teen 2)*

$499: Program Membership

All sales are final. No refund issued after registration.

Would you like to add a 3rd Teen to this registration form?*

Yes

Teen 3 Information

Teen 3 Name*

First Last

Grade in Fall 2026 (Teen 3)*

Which school will you attend in Fall 2026? (Teen 3)*

Teen 3 Birthday*

Teen 3 Gender*

Teen 3 Email*

Teen 3 Phone Number*

Teen 3 T-Shirt Size (adult sizes)*

Program Cost (Teen 3)*

$499: Program Membership

All sales are final. No refund issued after registration.

Parent1/Guardian Information

Parent 1 Name*

First Last

Parent 1 Email*

Parent 1 Phone Number*

Parent 1 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent2/Guardian Information (Optional)

Parent 2 Name

First Last

Parent 2 Email

Parent 2 Phone Number

Is your Parent 2 Address the same as Parent 1 Address?

Yes, address is the same

Parent 2 Address (if different from Parent 1)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information

Other than parent or guardian

Emergency Contact Name*

First Last

Emergency Contact Phone Number*

Emergency Contact Email*

Payment Summary

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Total

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Teen Information

Teen 2 Information

Teen 3 Information

Parent1/Guardian Information

Parent2/Guardian Information (Optional)

Emergency Contact Information

Payment Summary

Proceed With Payment

Connecting North Carolina Jewish Teens to Israel and Each Other

Marcy Braverman Goldstein, PhD

Lena Kosinovsky

Registration

Teen Information

Teen 2 Information

Teen 3 Information

Parent1/Guardian Information

Parent2/Guardian Information (Optional)

Emergency Contact Information

Payment Summary

Please Read and Confirm The Waiver Form

Proceed With Payment

Connecting North Carolina Jewish Teens to Israel and Each Other