Subsidized Teen Civil Rights Journey – Jewish Federation of Greater Pittsburgh

Teen Civil Rights Journey Registration

"*" indicates required fields

Application Process

Participants must be fully vaccinated to attend. To participate in this capstone experience, final acceptance will be decided after an interview and include consideration of personal statements. This will help to assure that the program and applicant are a good match. The interview will be arranged upon receipt and review of the application.

Name*

First Last

Name as you would like it on name tag*

Gender? Pronouns?

Birthdate*

Grade currently attending in school*

Name of part-time Jewish school program*

Teen's Email*

Home Phone*

Teen's Cell Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Specify any dietary needs (kosher, lactose intolerant, vegetarian, etc.):

T-shirt Size*

Have you ever participated in a summer program?*

Yes

Specify any behavioral/psychological issues or past traumatic events:

Applicant Photo*

Max. file size: 128 MB.

Please include a recent clear photo of the applicant.

Parent Information

Parent 1 Name*

Parent 1 Email*

Parent 1 Cell Phone*

Parent 2 Name*

Parent 2 Email*

Parent 2 Cell Phone*

Does the applicant live with both parents?*

Yes

Teacher Reference

Please provide the name and email address of a high school teacher. We will send an email to the teacher that addresses the applicant's academic ability to take advantage of the educational aspect of the capstone experience. We will send an automated survey email to the teacher reference.

Name of Teacher*

Teacher's Email*

Emergency Contact

Please provide the name and contact information for the person who would be reliably available during the time of the trip.

Emergency Contact Name*

Relationship to Applicant*

Emergency Contact Phone - Day*

Emergency Contact Phone - Evening*

Emergency Contact Phone - Cell*

Health Insurance Company*

ID Number*

Benefits Phone Number*

Health Insurance Card*

Max. file size: 128 MB.

Please upload photos or a scanned image of the front and back of the participant's health insurance card.

Personal Statements

Please complete the questions below. Statements should be the applicant's original thoughts. Please limit each statement to 300 words.

Why do you want to participate in the Teens Civil Rights Journey?*

What challenges do you face as a Jew and American?*

What is America to you? Include thoughts on what is the American dream, what responsibilities, if any, come with being an American citizen, what are the strengths and problems of America.*

Agreements

Photo Release and Liability Agreement*

By registering for this event, the participants agrees that their picture and/or video may be taken and potentially used in Jewish Federation marketing material and social media.

Yes, I/(we) agree.

Payment Information

When you submit your application, you will be redirected to a payment form to complete your registration. Thank you.

Comments

This field is for validation purposes and should be left unchanged.