Teen Civil Rights Trip 2024 - Form - Temple Israel Center

Join TIC Clergy, Staff, and Teens as we join Tzedek America for an impactful Arizona Immigration Justice Program.

Visit Phoenix, Tucson, and the border town of Nogales, Arizona, on this impactful immigration justice program. We will meet with organizations and people directly addressing the migration issues and enforcing the flow of migrants from Mexico to the United States. We will meet with activists, homeland security agents, border patrol, retired border patrol, humanitarians, and state officials. The goal is to give a complete picture of the complex and layered issue of immigration in our country.

Dates:
April 11-14, 2024
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Cost:
$2,353 per person (Flight Included)

Payment Schedule:
$350 deposit due at time of registration to secure your spot on the trip.
Final payment due: November 6, 2023
Registration closes October 23, 2023

* Are you a member of TIC?

Please Select OneYesNo

In registering below, I grant Temple Israel Center permission to use photos of my family members, including children (neither photos nor captions will contain any names) in synagogue publications, including but not limited to slideshows, newsletters, emails, flyers, our Facebook pages and Instagram, and the TIC website.

Teen #1 Information

* Teen #1 - First Name

* Teen 1 - Last Name

Teen #1 Email

Teen #1 Phone Number

* Teen #1 - Year in School (Fall 2023)

* Payment Options

Registration is only considered complete once the deposit is paid. At this time, you may choose to pay in full or just the deposit. The full payment is due by November 6, 2023.

Would you like to register a 2nd Teen?

SelectYesNo

Teen #2 Information

Teen #2 - First Name

Teen #2 - Last Name

Teen #2 Email

Teen #2 Phone Number

* Teen #2 - Year in School (Fall 2023)

* Payment Options

Registration is only considered complete once the deposit is paid. At this time, you may choose to pay in full or just the deposit. The full payment is due by November 6, 2023.

Would you like to register a 3rd Teen?

SelectYesNo

Teen #3 Information

Teen #3 - First Name

Teen #3 - Last Name

Teen #3 Email

Teen #3 Phone Number

* Teen #3 - Year in School (Fall 2023)

* Payment Options

Registration is only considered complete once the deposit is paid. At this time, you may choose to pay in full or just the deposit. The full payment is due by November 6, 2023.

Would you like to register a 4th Teen?

SelectYesNo

Teen #4 Information

Teen #4 - First Name

Teen #4 - Last Name

Teen #4 Email

Teen #4 Phone Number

* Teen #4 - Year in School (Fall 2023)

* Payment Options

Registration is only considered complete once the deposit is paid. At this time, you may choose to pay in full or just the deposit. The full payment is due by November 6, 2023.

Parent/Guardian #1 Information

* Parent/Guardian #1 First Name -

* Parent/Guardian #1 Last Name

* Parent/Guardian #1 Cell Phone

* Parent/Guardian #1 Email

* Parent/Guardian #1 Home Address

* Parent/Guardian #1 City

* Parent/Guardian #1 State

* Parent/Guardian #1 Zip Code

Parent/Guardian #2 Information

Parent/Guardian #2 First Name -

Parent/Guardian #2 Last Name

Parent/Guardian #2 Cell Phone

Parent/Guardian #2 Email

Home Address IF DIFFERENT - Parent/ Guardian #2

SelectNoYes

Home Address - Parent/Guardian #2

Parent/Guardian #2 City

Parent/Guardian #2 State

Parent/Guardian #2 Zip Code

Emergency Contact Information

* Emergency Contact: First Name

* Emergency Contact: Last Name

* Emergency Contact Phone

* Please list any medications you will be bringing with you on the trip. If none please indicate N/A below:

* Please list any allergies or dietary restrictions you have. If none please indicate N/A below:

* Please upload a copy of your insurance card:

Payment:

Total Due