CTeen Membership

Teen's Name*

First NameLast Name

Hebrew Name

Birth Date*

MonthDayYear

Teen's Cell*

Area CodePhone Number

Teen's E-mail*

School*

Grade*

Previous Jewish Education

YesNo

Where

T-Shirt Size*

Mother's Name*

First NameLast Name

Hebrew Name

Mother Cell*

Area CodePhone Number

Mother's E-mail

Is mother Jewish

YesNo

Father's Name*

First NameLast Name

Father's Hebrew Name

Father's Cell*

Father's Email

Is Father Jewish

YesNo

Address*

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

Home Phone

Area CodePhone Number

Please Indicate if child is adopted*

YesNo

Has anyone in the family converted*

YesNo

If yes, please indicate who and by which officiating Beth Din

Congregation Membership

Does either parent have any special skill or resource to offer our club?

Emergency Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Doctor*

First NameLast Name

Phone Number*

Area CodePhone Number

Allergies and/or other known conditions we should be aware of

If parents can not be reached and emergency medical advice is needed, permission is granted to phone my child's doctor. In case of medical emergency requiring immediate emergency care, I authorize transportation to nearest medical facility*

I Agree

I, the legal parent/guardian, authorize you and your agents to involve our child in these various trips and activities, direct you to rely upon the registration forms previously tendered for emergency contact persons for the benefit of our child, authorize the administration of any medicines deemed necessary by emergency health professionals in the event of non-availability of parent/guardian, acknowledge that all known allergies or other conditions impacting the health and well being of our child are listed below, and further release the Chabad and its agents from liability arising during the course of these various field trips and activities*

I Agree

I/we understand that my/our child(ren) may be included in photographs and video footage that may be photographed or filmed during CTeen. I authorize CTeen and Chabad of Wilmette to use these photos/videos to promote its programs and services in print, web, and other promotional contexts*

I Agree

Payment Options*

$99- CTeen Yearly Membership Fee (includes discounted monthly events, Classes, and discounted NYC and more Shabbaton's of 2018/2019)

Payment

Credit Card Paypal

Postal / Zip Code

Country

Total

$0.00

CTeen Membership

Parents Information

General Information

Emergency Information

Permissions

Payment