2021/2022 Teen Moadon Registration Form

MakomNY Teen Moadon Registration Form

2021-2022
MakomNY TEEN MOADON PROGRAM
with Rabbi Deborah Bravo

An Engaging and Special Twice Monthly Program
for 8th - 12th Grade Students

Monthly Tuesday or Wednesday Evenings, 6:30 to 8:00 pm
in Bethpage Worship Center
Pizza and salad dinner will be provided.
Regular mitzvah opportunities at Teen events.

Monthly Weekend Social and Experiential Opportunities
including programs like: Bowling, Lower East Side Trip,
Dave & Busters, 9-11 Memorial Visit, Escape Rooms,
Movie Theater Night and More!

Our MakomNY Teens in 8th - 12th grades meet twice a month with Rabbi Bravo for informal gatherings with a focus on social action, social justice, topical issues, and great social opportunities. Our teens and their specific interests drive much of the topics and activities.

During the year there will be several specific sessions for 11th and 12th grade students to both socialize and prepare for college.

Tentative Schedule for 2021-2022 Can Be Found HERE

The cost for the Teen Moadon Program is just $180 for the entire year, which includes all Bethpage events. You can also choose to pay program by program.

Please note that all off-site programs do require an additional fee for each participant. Teens must pre-register for these off-site events on the Teen Special Event Form.

For those who are currently part of the Shorashim Monthly Donation Program (at the appropriate level): There are no additional fees for Teen Programs that take place in Bethpage Worship Center .

Please complete this form ONCE to register your teen for the year.
Parent 1 Name*

First NameLast Name
Parent 1 Cell Phone*

Area CodePhone Number
Parent 1 Email*
example@example.com
Parent 1 Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2 Name

First NameLast Name
Parent 2 Cell Phone

Area CodePhone Number
Parent 2 Email
example@example.com
Teen 1 Information

Please complete all information. You only need to complete this form once.
Teen 1 Name*

Full First NameLast Name
Teen 1 Nickname
Teen 1 Cell Phone*

Area CodePhone Number
Teen 1 Email*
example@example.com
Teen 1 Grade for 2021-22 School Year*

8th Grade9th Grade10th Grade11th Grade12th Grade
Teen 1 School*
Teen 1 Allergies - Please let us know any allergies.
Teen 1 - Please upload a copy of your child's school medical form.

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Teen 2 Information

Please complete these section if you have a second teen eligible for our program.
Teen 2 Name

Full First NameLast Name
Teen 2 Nickname
Teen 2 Cell Phone

Area CodePhone Number
Teen 2 Email
example@example.com
Teen 2 Grade for 2021-22 School Year

8th Grade9th Grade10th Grade11th Grade12th Grade
Teen 2 School
Teen 2 Allergies - Please let us know any allergies.
Teen 2 - Please upload a copy of your child's school medical form.

Browse Files

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If you would like, please expand on what you would like your teen(s) to gain from the MakomNY Teen Program or anything else about your teen's interests or personality.
Parent Signature - Yes, I give permission for my teen(s) to participate in the Makom Teen Moadon for the 2021-2022 year. *

Clear
How would you like to financially support the Teen Moadon Program?*

We are currently participating in the Shorashim Program at the appropriate level (minimum of $54/month with kids in K-7 Moadon, minimum of $90/month with kids in 8th grade or higher).We will pay the $180 annual fee for the Teen Moadon program, which allows our child to participate in all of the regular teen programs. (There will be additional fees for off-site programs.)We will pay $360 for two teens to participate in all of the regular teen programs. (There will be additional fees for off-site programs.)We will pay per program, as we go through the year. Each gathering in Bethpage, including dinner and program, is $20/teen.
Payment for Teen Program

Total Payment Amount

USD

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

MakomNY Teen Moadon Registration Form

Teen 1 Information

Teen 2 Information