PLEASE NOTE: Fields marked with a RED ASTERISK* are mandatory. Please complete this form to register ALL students in your family for Shorashim (Grades K-6) and/or Havurat Torah (Grades 7-12) To submit, go to the last page using the navigation buttons at the bottom and click the submit button (bottom of last page). A confirmation page will be emailed to you. Friend and session requests will be honored only upon receipt of a deposit. Questions? Please contact Jean Klipstein in the Education office, or at (914) 948-2800 x123. Thank you. ADULT information Adult 1 First Name * Last Name * Email * Preferred email address for Shorashim/Havurat Torah correspondence Phone * Preferred phone number for Shorashim/Havurat Torah communication Business Phone Number Street Address (home) * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Adult 2 First Name Last Name Email Preferred email address for Shorashim/Havurat Torah correspondence Phone Preferred phone number for Shorashim/Havurat Torah communication Business Phone Number Street Address (home) City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code SYNAGOGUE AFFILIATION Are you a member of Temple Israel Center? * Yes No May join in the near future Media RELEASE cONSENT Please indicate if we can use your child(ren)'s photograph or likeness in photo, video, or printed marketing and/or promotional materials (names will not be included) for Shorashim, Havurat Torah, or Temple Israel Center. Media release * Yes No Parent/Guardian Electronic Signature First & Last Name *