Teen Event: Pizza, Prayer, Pajamas

* Teen Name

* Teen Cell Phone

* Parent Name (Emergency Contact)

* Parent Phone (Emergency Contact)

Dietary Needs

Gluten FreeDairy FreeVeganNut Free

Please indicate any dietary needs or sensitivities we should be aware of

Other Allery of Medical Need

Please indicate any environmental allergies or medical needs our staff should know about

Authorization-consent Release: In the event of an emergency at either Temple Sinai of Bergen County or during an off-site program or event, and if the parent listed above cannot be reached, please indicate whether you authorize Temple Sinai of Bergen County to act as your agent and arrange for medical treatment or hospital care for your child/children. If you agree to have the Temple act as your agent in the event of any emergency, then you agree to release Temple Sinai of Bergen County and any of its officers, directors, staff or employees from any and all claims arising from such authorization.

* Authorization to Treat

Please Select OneYesNo

	Already Enrolled in 2025-2026 Temple Sinai Teen Programs Free
	Temple Sinai Member (Event-Only Registration) $5.00
	Temple Emeth Member (Event-Only Registration) $5.00
	Adas Emuno Member (Event-Only Registration) $5.00
	Non-Member (Event-Only Registration) $5.00
	* Teen Name * Teen Cell Phone * Parent Name (Emergency Contact) * Parent Phone (Emergency Contact) Dietary Needs Gluten FreeDairy FreeVeganNut Free Please indicate any dietary needs or sensitivities we should be aware of Other Allery of Medical Need Please indicate any environmental allergies or medical needs our staff should know about Authorization-consent Release: In the event of an emergency at either Temple Sinai of Bergen County or during an off-site program or event, and if the parent listed above cannot be reached, please indicate whether you authorize Temple Sinai of Bergen County to act as your agent and arrange for medical treatment or hospital care for your child/children. If you agree to have the Temple act as your agent in the event of any emergency, then you agree to release Temple Sinai of Bergen County and any of its officers, directors, staff or employees from any and all claims arising from such authorization. * Authorization to Treat Please Select OneYesNo
Total	$

Saturday, October 11, 2025 • 19 Tishrei 5786

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