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ב"ה

CTeen Membership

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*
Parents Information
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
General Information
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 Information
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
Permissions
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
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
Should be Empty:

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