Cteen Registration

Home Address*

Part 2: Parent Information
Parent's relationship*

MarriedDivorcedSeparated
Father's Name

First Name Last Name Hebrew Name
Father's Birth Date

Month Day Year
Father's E-mail
Father's cell

Area Code Phone Number
Mother's Name*

First Name Last Name Hebrew Name
Mother's Birth Date*

Month Day Year
Mother's E-mail*
Mother's cell*

Area Code Phone Number
Part 3: Medical Information
Person to be contacted in case of an emergency when parents cannot be reached.
Full Name*

First Name Last Name
Phone Number*

Area Code Phone 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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Programs

Part 1: Teen Info