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Torah at the Table Registration
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Parent Information
*
Parent #1 First Name
*
Parent #1 Last Name
*
Parent #1 Email
Parent #1 Cell Phone
Parent #2 First Name
Parent #2 Last Name
Parent #2 Email
Parent # 2 Cell Phone
*
Home Address for Student(s)
*
City, State, Zip
Do Both Parents Live at the Same Address?
Yes
No
If Not, What is the Second Address
*
May we take & use your child(ren)'s photo?
Please Select One
Yes
No
Student Information
*
Student First Name
*
Student Last Name
Student Gender
Female
Male
Non-Binary
*
Student Date of Birth
Student Hebrew Name
*
Student Grade as of January 2024
*
Student Public/Day School
Student has an IEP
Yes
No
Student Allergies or Medical Concerns
Fri, January 17 2025 17 Tevet 5785
