College Age Youth

* Parent(s) Names

* Parent Email

* Student's First Name

* Student's Last Name

* Student's Email

Student's Cell #

* Gender

Please Select OneMaleFemaleOther/Prefer not to say

Student's Birthday

Alternative Birthday Input

If you get frustrated with the nifty calendar widget for entering the date. Please enter mm/dd/yyyy.

What is the other allergy/dietary restriction?

* Name of University/College

My student is currently living at home

NoYes

If currently living at home and attending virtual classes, when are the expected to move back to college?

* Graduation Year

Student’s College Mailing Address
(If not currently virtual from home)

Can we provide your contact information to Temple Shaari Emeth High School Students if they have questions about your college to aid in their college search?

YesNo

* Street Address/PO Box

2nd Address Line

optional

* City

* State

* Zip Code

Country (If not U.S)

Comments

Given the unique challenges that college students are dealing with during the pandemic, please include in the comments section of the form any information about school vacation dates and extended periods at home that would help the Youth Committee with their mailings Thank you.

Please consider a donation to support our College Student outreach

Please select an amount or choose other$18$36Other amount (please indicate amount)

Other amount

please enter here if you selected "other amount"

Total

College Age Youth Connection