If you require financial assistance, please contact Michelle Napell at 609-987-8100 before completing the following application.

Application Information

Student First Name*
Student Last Name*
Parent Name(s)*

If your mailing address is different from your billing address, please fill out your mailing address here. Otherwise you may leave these fields blank.

Address Line 1
Address Line 2
City
State
Zip
Home Phone*
Parent Cell Phone*
Student Cell Phone
Student Email
Student Birthdate (mm/dd/yyyy)
Parent Email*
Parent Work Phone
Synagogue Affiliation (if none, please type NONE)*
School*
If this is your first year in JCYF, how did you hear about JCYF? (check all that apply)
  • Mailing
  • Email
  • Synagogue
  • Website
  • Word of Mouth

Recommend a Friend! Please provide name & contact information for 8th - 10th grade teen(s) you think would be interested in JCYF.

Friend's Name & Contact Information

If the JCYF has more than one group and you have a preference for your placement, please list below 2 friends that you would like to be placed with. Note: when listing friends, please make sure the corresponding friend(s) list(s) you. JCYF cannot guarantee placement in a particular group.

Friend Request 1
Friend Request 2

While we understand that teens have many demands on their time, we want you to make your best effort to commit to attending all JCYF meetings of the program including your site visit. It will be well worth it!

Youth Advisory Board

The Youth Advisory Board is an additional JCYF enrichment program. It is comprised of class representatives who participate in additional leadership training, provide feedback about the Jewish Community Youth Foundation program, and plan a day of community service.

 

If you are interested in participating in the JCYF Youth Advisory Board, please visit http://jcyfonline.blogspot.com/p/youth-advisory-board.html to complete an application for this additional program. There is no added cost.

 

Health Insurance Information

Insurance Carrier*
Subscriber*
Policy Number*
Group Number*
In case of emergency, if parent cannot be reached, contact name:*
Emergency Contact Phone*
Emergency Contact Relationship to Student*
Doctor's Name*
Doctor's Phone*
Dentist's Name*
Dentist's Phone*
List your child's known allergies (if none please type NONE):*
List your child's prescription medications, dosages, and schedules:
Is there any additional information that the staff should know?

Payment Amount

The $350 Registration Fee includes participation fee & donation. 

* If you are not paying the full $350, please indicate why in the additional comments section of the payment information below.

Donation Amount*
  • $350
  • Other $

Payment Contact

Country*
Email*
Confirm Email*
Phone*

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

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