Beneath the Surface for All: Temple Isaiah Fall 2024

Information about the Adult

Your Name*

Your Gender

Your Pronouns*

Your Email*

Phone*

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

How did you hear about this program?*

Please describe*

I confirm that we are available to attend Beneath the Surface for All on September 8, 15, & 22 from 3-5pm*

Yes

Information about the Youth

Youth's Name*

Youth's Gender

Youth's Pronouns*

B-Mitzvah Date*

Youth's Email (we will not contact)

Youth's date of birth*

Identity Information

The identity questions below will be used to advance our diversity, equity, and inclusion goals, to learn more about our community, and to measure the impact our programs are having on the broader Jewish community. As a non-profit organization, at times our funders are interested in this information as well.

How do you describe your ethnic identity (Ashkenazi, Sephardi, Mizrahi, etc.)?

How do you describe your youth's ethnic identity (Ashkenazi, Sephardi, Mizrahi, etc.)?

Do you identify as a member of the LGBTQ+ community?

Yes
No
Prefer not to answer

Do your youth identify as a member of the LGBTQ+ community?

Yes
No
Prefer not to answer

Do you identify as having a visible or invisible disability?

Yes
No
Prefer not to answer

Do your youth identify as having a visible or invisible disability?

Yes
No
Prefer not to answer

Do you identify as Black, Indigenous, or a Jew of Color?

Yes
No
Prefer not to answer

Does your youth identify as Black, Indigenous, or a Jew of Color?

Yes
No
Prefer not to answer

Is there anything about your identities that you would like us to know?

Payment Information

Registration fees cover expenses for expert facilitators and educators, supplies, food, and curriculum development. The cost to run this program is $450 per person. Registration is offered on a sliding scale to accommodate people of all financial abilities. In order to offer this program sustainably, we need participants to register at every level of the sliding scale, including those above the suggested amount. Please choose the registration level that is most appropriate for you based on your financial capacity. Thank you for helping to ensure that people of all identities and backgrounds can access this program.

I am registering with the following sliding scale...*

Support Participation for All sliding scale: $275-$450 (Suggested: $395)
Standard Registration sliding scale: $180-$360 (Suggested: $250)
Need-based & low-income financial aid sliding scale: $36-$180 (Suggested: $100)

Support Participation for All*

Please enter a number from 275 to 450.

Standard Registration*

Please enter a number from 180 to 360.

Need-based & Low-income Financial Aid*

Please enter a number from 36 to 180.

Registration Total

Price: $0.00

Credit Card*

American Express

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MasterCard

Visa

Card Number

Expiration Date

Security Code

Cardholder Name

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