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Cteen Registration

Cteen Registration

Register Online

Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, feel free to call our director Rivky Vaisfiche at 516-387-4359 or email info@Melvilliechabad.com .

Teen Profile

 

Last Name

First Name

Hebrew Name

Age

DOB

 

 

Time of Birth - In Judaism the day begins at nightfall, so in order to determine the exact date of your Jewish birthday we need to know what time of day you were born.

School

Grade Entering

 

  

Parent Information

 

Address

City/Zip

Phone

Father's Name

Father's Occupation

Father's Cell

Father's Email

Mother's Name

Mother's Occupation

Maternal Grandmother born Jewish?

Mother born Jewish?

Converted by whom?

Mother's Cell

Mother's Email

 

Emergency Information

 

Emergency Contact 1

Phone

Emergency Contact 2

Phone

Doctor's Name

Doctor's Phone Number

Medical Insurance Company

Policy Number

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

Registration Payment Agreement

Please check box with your choice for method of payment.

Prepayment in full before October 1st

Pay ½ of tuition before October 1st, and ½ by January 15.

Other method of payment as arranged with the office.

Agreement

 As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of CTeen Jr. to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, CTeen Jr. personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all activities, join in trips on and beyond school properties and allow my child to be photographed while participating in CTeen Jr. activities and that these pictures may be used for marketing purposes.

I Accept
I grant my child permission to join all Cteen Jr. trips and transportation to trips.

Name: Initials: Date:

 

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