Name of Person Completing this Form*

Relationship to Teen*

Teen's Name as it Appears on Official Identification (passport, license, driver's permit or school ID)*

Teen Street*

Teen City*

Teen's Cell*

Teen's Personal Email (not school)*

Allergies
*

Medical Conditions
*

Is teen currently being treated by a mental health professional?
YesNo*

If yes, please explain.

List Medications Teen is Currently Taking
*

Parent 1/ Guardian 1 Name*

Parent 1/ Guardian 1 Street*

Parent 1/ Guardian 1 City*

Parent 1/ Guardian 1 Cell*

Parent 1/ Guardian 1 Email*

If applicable:

Parent 2/ Guardian 2 Name

Parent 2/ Guardian 2 Street

Parent 2/ Guardian 2 City

Parent 2/ Guardian 2 Cell

Parent 2/ Guardian 2 Email

Name of custodial parent(s):

Considering the heavy topic of the Holocaust, please tell us anything we should know about your child and how to best support them during the course.

Was or is there a family member or close friend who is a Holocaust survivor?
YesNo

If yes, feel free to share details.

Thank you for completing this form. If you have any questions or concerns, please contact Natasha Tsaryuk at 978-810-6399 or email natasha@lappinfoundation.org.

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