Road Trip Registration Form 2026

TEEN INFORMATION
Teen's Full Name*
First Name Last Name
Birth Date*

Month Day Year
Current School *
Current Grade*
T-Shirt Size*

SMLXLXXL
PARENT INFORMATION
#1 Parent's Name*
First Name Last Name
#1 Parent's E-mail*
#1 Phone Number*
#2 Parent's Name*
First Name Last Name
#2 Parent's E-mail*
#2 Phone Number*
Parents' Marital Status*

MarriedDivorced

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Is the teen's mother Jewish?*

by birthby conversionNot Jewish
Is the teen's father Jewish?*

by birthby conversionNot Jewish
Are there any adoptions in the family?*

YesNo
Teen's Hebrew Name
Mother's Hebrew Name
Personal Reference on behalf of camp: Name*
Personal Reference on behalf of camp: Email*
Personal Reference on behalf of camp: Phone#*
PRICING
CTeen's programming on behalf of our youth is only possible with the help of donors. If you are in the position to help others attend or to help with the full cost of the trip, please click here - this should be a check box.

Tier 1 Discounted Price $2600
Tier 1 is a discounted rate to help make our road trip more affordable and available for Jewish teens.

Tier 2 Subsidized Price $1900
Tier 2 is a more heavily discounted rate to enable families for whom it is difficult to afford Jewish camp.

Tier 2 must also apply to the two scholarships below to help CTeen cover costs in event of approval (and obviously, Tier 1 can apply as well).
Please indicate:*

Tier I - $ 2,600Tier II - $1,900
GRANT & SCHOLARSHIP INFORMATION
ONE HAPPY CAMPER GRANT
CTeen Boca is proud to be a participant in the One Happy Camper grant programs. Qualifying campers will be eligible for a grant of $700. Please click here for more information.

JEWISH FAMILY SERVICES SCHOLARSHIP
Scholarships up to $1000. Please click here for more information .
Please note the Grant and Scholarship you are applying for:*

One Happy Camper GrantJewish Family Services ScholarshipNot applying
Comments/Questions
PAYMENT
I acknowledge $ 50 is due at this time.*

Yes
Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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TEEN INFORMATION

PARENT INFORMATION

PRICING

GRANT & SCHOLARSHIP INFORMATION

PAYMENT