NADAV Teen Program Registration 23-24 - Form

Welcome to the 2023/24 NADAV Teen Internship program!

We have an exciting year ahead! Thanks to a generous donation we have expanded our monthly social/educational programming schedule which includes day trips to out of state destinations!

We are asking families to pay $250 per intern to support NADAV this year. These funds are being matched 4-fold via a foundation grant! (You also will find instructions for requesting financial aid below.)

To register, please fill out the form below. The second page will have have payment information.

HAVE AN ACCOUNT? PLEASE click the "Login" dropdown at the top right of this page and log in.
If you don't have an account, please proceed to fill out the form. If you have form questions, please contact Sophie.

* How many teens will you be registering for NADAV this year?

NADAV TEEN INFORMATION

* Teen's Full Name

* Date of Birth

Pronouns

* Student's current grade and school

Student Email

Student Phone

If other:

Allergies, medical conditions, medicines and special needs

Please tell us about any allergies and medical conditions that your child has. Please also list all medicines that this child takes regularly. Include special services this child receives in secular school, and if you feel it would be helpful for the Nadav staff to contact their secular school teacher, please include the contact information.

* 2nd Teen's Full Name

Date of Birth

Pronouns

* Student's current grade and school

Student Email

Student Phone

If other:

Allergies, medical conditions, medicines and special needs

Please tell us about any allergies and medical conditions that your teen has. Please also list all medicines that this child takes regularly. Include special services this child receives in secular school, and if you feel it would be helpful for Nadav staff to contact their secular school teacher, please include the contact information.

* 3rd Teen's Full Name

Date of Birth

Pronouns

* Student's current grade and school

Phone

* What internship areas interest this teen?

If other:

Allergies, medical conditions, medicines and special needs

Please tell us about any allergies and medical conditions that your teen has. Please also list all medicines that this teen takes regularly. Include special services this child receives in secular school, and if you feel it would be helpful for Nadav staff to contact their secular school teacher, please include the contact information.

* 4th Child's Full Name

Date of Birth

Pronouns

* Student's current grade and school

* Allergies, medical conditions, medicines and special needs

* What interests your student(s) in participating in NADAV?

* Are there any skills the parents/guardians are interested in sharing with the program?

* Are there skills your student would like to learn in the program?

* Is your family affiliated with a synagogue or religious organization? If so which one?

ADULT 1 INFORMATION:

If only one adult is a member of OZ, please put their information under Adult 1

* Adult 1's First Name

* Last Name

* Email

(This is your OZ Shulcloud login email.)

* Cell Phone

Home Phone

Work Phone

* Street Address Line 1

Street Address Line 2

* City

* State

* ZIP

* We are proud to be an inclusive & diverse community! Please select the option that best describes you.

Other, If Applicable:

ADULT 2 INFORMATION:

First Name

Last Name

Cell Phone

Home Phone

Work Phone

Street Address Line 1

Street Address Line 2

City

State

ZIP

We are proud to be an inclusive & diverse community! Please select the option that best describes Adult #2:

Other, If Applicable:

EMERGENCY CONTACT INFORMATION

* First Emergency Contact Name:

* Phone:

* Relationship to you:

* Second Emergency Contact Name:

* Phone:

* Relationship to you:

EMERGENCY MEDICAL CARE

* Physician's Name:

* Physician's Phone:

* Health Insurance Company:

* Policy Number:

* Emergency Medical Care

Emergency Medical CareIn case of accident or serious illness, I request that Ohavi Zedek contact me. If OZ is unable to reach me, I hereby authorize OZ personnel to seek emergency medial care, including transportation to the emergency room. I hereby authorize the physician in charge to administer whatever treatment necessary at my expense.

IMAGE RELEASE

Print and Online Publication

Print and Online Publication Participants at OZ programs may be photographed and recorded for the purposes of educational enrichment, member engagement and publicity. By giving approval, it is understood that you, as the child's legal guardian, grant permission to Ohavi Zedek Synagogue, its employees and its legal representatives, to publish, without charge, images taken of your child on Ohavi Zedek Synagogue premises or in conjunction with an Ohavi Zedek Synagogue event or for the purpose of an Ohavi Zedek Synagogue publication. These images may be used in any and all Ohavi Zedek Synagogue publications, including electronic materials, website, social media outlets, audio/visual presentations, promotional literature and/or advertising.

VOLUNTEER OPPORTUNITIES FOR PARENTS/GUARDIANS

COST

Number of participants (at $250 each):

The program has space set aside for those not able to pay. To request free or discounted participation, please contact N aomi. We will reply promptly and with discretion.

On the next page, you will see payment options, including paying by credit card or ACH (e-check).

(Avoid credit card charges and pay via ACH!)

For questions please contact Naomi.