JEP boys of MD Registration Form

JEP Boys Registration Form

We are so excited to meet you!
Participant Information
Participant's Name

First NameLast Name
Birthday

MonthDayYear
Participant's Cell Phone Number

Area CodePhone Number
Participant's Email
Grade
School
Does the participant attend Hebrew School?
Hebrew School
Synagogue Affiliation
Does the participant have any allergies?
Please list participant's allergies:
Important Information/Special Concerns:

Family Information
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number

Area CodePhone Number
Mother's Name

First NameLast Name
Mother's Email
Mother's Cell Phone Number

Area CodePhone Number
Is mother's home address the same as participant?
Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Father's Name

First NameLast Name
Father's Email
Father's Cell Phone Number

Area CodePhone Number
Is father's home address the same as participant?
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parents' Marital Status
Other:
Does the participant have a stepparent?
Stepparent via
Stepparent's Name

First NameLast Name
Stepparent's Email
Stepparent's Cell Phone Number

Area CodePhone Number
Second Stepparent via
Second Stepparent's Name

First NameLast Name
Second Stepparent's Email
Second Stepparent's Cell Phone Number

Area CodePhone Number
Please list participant's siblings and ages:
Emergency Contact (if parents unreachable)

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Participant

Would you like to purchase a JEP sweatshirt?
Sweatshirt Size
How did you hear about JEP?
Other
Name of Friend
I hereby give consent for my child to participate in this JEP event. I understand that JEP takes photos and videos during events and posts them to the JEP website and social media and give permission for my child's photos to be included in promotional materials. Any lost and found items not claimed within 30 days will be donated or discarded. I understand that if my child has a medical need, JEP will make a conscientious effort to notify my spouse or me. In the event that this is not possible, I give permission for JEP of Maryland and its staff, or person designated, to make available to my child professional emergency medical care when such care is indicated. I give permission for my child to receive proper medical care by any doctor, nurse, paramedic, or member of a medical staff of a hospital.
Parent's Name

First NameLast Name
Email Address
Date

MonthDayYear
By submitting this form you consent to receive messages from JEP of MD, at 410.929.0JEP (0537). Msg and data rates apply and will be sent on a frequency that meets your needs. You can opt out at any time by texting STOP. Please view our privacy policy at https://jepgirls.org/privacy.html.
Total

Total

USDSweatshirt

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty: