2026 TEEN CIVIL RIGHTS JOURNEY APPLICATION FORM

Please complete the form below. Required fields marked with an asterisk *

2026 TEEN CIVIL RIGHTS JOURNEY APPLICATION FORM

2026 Dates - November 1-3, 2026

(Sunday-Tuesday)

STUDENT INFORMATION

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Date of Birth*

Answer required for "Date of Birth"

Grade as of September 2026*

Answer required for "Grade as of September 2026"

9th Grade

Other:

Gender*

Answer required for "Gender"

Male

Female

Other:

Student Phone*

Number Required

Student Email*

Answer required for "Student Email"

Student School*

Answer required for "Student School"

Are there any learning needs, accommodations, or supports that would help us create the best experience for your teen?

Answer required for "Are there any learning needs, accommodations, or supports that would help us create the best experience for your teen?"

IMPORTANT MEDICAL INFORMATION (Allergies, prescriptions, illness presently under physician's care, etc.)

HEATH INSURANCE CARD 01 - Please upload image or pdf copy of the student Health Insurance (card front)*

Answer required for "HEATH INSURANCE CARD 01 - Please upload image or pdf copy of the student Health Insurance (card front)"

Choose a file or drag it here.

HEATH INSURANCE CARD 02 - Please upload image or pdf copy of the student Health Insurance (card back)*

Answer required for "HEATH INSURANCE CARD 02 - Please upload image or pdf copy of the student Health Insurance (card back)"

Choose a file or drag it here.

Describe any health-related concerns (e.g. heart problems, diabetes, etc.):

Answer required for "Describe any health-related concerns (e.g. heart problems, diabetes, etc.):"

Medication Responsibility. Please select one:*

Answer required for "Medication Responsibility. Please select one:"

My child does not take any medication

My child will carry and self-administer their medication

I give permission for staff to hold and administer my child’s medication as needed

Current Medications: Please list all medications your participant is currently taking. Include: Medication name Dosage Frequency (e.g., once daily, as needed) Administration instructions (e.g., with food, time of day, etc.)

Answer required for " Current Medications: Please list all medications your participant is currently taking. Include: Medication name Dosage Frequency (e.g., once daily, as needed) Administration instructions (e.g., with food, time of day, etc.)"

Dietary Requirements - All meals provided will be kosher-style. As local catering options are limited, if your child requires strictly kosher (hechshered/sealed) meals, please contact Sydney Milgrom*

Answer required for "Dietary Requirements - All meals provided will be kosher-style. As local catering options are limited, if your child requires strictly kosher (hechshered/sealed) meals, please contact Sydney Milgrom"

None

Vegetarian

Vegan

Gluten-free

Dairy-free

Other:

PARENTS INFORMATION

Parent 1 First Name*

Answer required for "Parent 1 First Name"

Parent 1 Last Name*

Answer required for "Parent 1 Last Name"

Parent 1 Phone*

Number Required

Parent 1 Email*

Answer required for "Parent 1 Email"

Parent 2 First Name

Answer required for "Parent 2 First Name"

Parent 2 Last Name

Answer required for "Parent 2 Last Name"

Parent 2 Phone

Number Required

Parent 2 Email

Answer required for "Parent 2 Email"

Address*

Answer required for "Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip Code*

Answer required for "Zip Code"

ADDITIONAL INFORMATION

Non-Parent Emergency Contact Name*

Answer required for "Non-Parent Emergency Contact Name"

Non-Parent Emergency Contact Relationship to Participant *

Answer required for "Non-Parent Emergency Contact Relationship to Participant "

Non-Parent Emergency Contact Phone Number*

Number Required

FINALIZING THE REGISTRATION PROCESS

To reserve your student’s spot on the Civil Rights Journey, you must complete the registration process and submit the program fee of $400.

Payment can be made by credit card or by check*.
If you need financial aid or a special payment arrangement, please contact Sydney Milgrom as soon as possible.

Credit Card Payment Breakdown

Program Fee: $400.00
Credit Card Processing Fee: $16.35
Total: $416.35

Check Payment Option

To avoid the additional credit card fee, you may send a $400 check payable to the Jewish Education Center of Cleveland. 2030 South Taylor Rd. Cleveland Heights, OH 44118.

I plan to use the following payment method:*

Answer required for "I plan to use the following payment method:"

Credit Card

Check

PARENT OR GUARDIAN SIGNATURE

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

2026 TEEN CIVIL RIGHTS JOURNEY APPLICATION FORM

Credit Card Payment Breakdown

Check Payment Option