Printed from ChabadOT.org

Cteen Registration

Part 1: Teen Info
Teen's Full Name*
First NameLast NameHebrew Name
Birth Date*
MonthDayYear
Gender*
MaleFemale
School (2018.19)*
Grade (2018.19)*
Cell Phone*
Area CodePhone Number

Home Address*

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

Part 2: Parent Information
Parent's relationship*
MarriedDivorcedSeparated
Father's Name
First NameLast NameHebrew Name
Father's Birth Date
MonthDayYear
Father's E-mail
Father's cell
Area CodePhone Number
Mother's Name*
First NameLast NameHebrew Name
Mother's Birth Date*
MonthDayYear
Mother's E-mail*
Mother's cell*
Area CodePhone Number
Part 3: Medical Information
Person to be contacted in case of an emergency when parents cannot be reached.
Full Name*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship to child*
In case of an emergency, I (we) authorize Chabad of Old Tappan to take whatever medical measures they deem necessary for my child in the event of a medical emergency.
Medical concerns or Allergies
Part 4: Agreements and Membership Fee
Agreements
We understand that as a member of Cteen, the applicant is responsible to show respect to others and to comply with instructions given by the directors.Permission is hereby given for the applicant to be photographed and for photos to be used in Cteen and Chabad of Old Tappan’s publications and social media.
Annual membership fee of $150 is optional. Membership fee does not include fees associated with social trips and transportation.
Payment Options
Pay now in full2 charges of $75 due on now and 1/1/19
Optional Donation
$54$180$360
Total Payment Due Today
$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

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