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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 .

Teen Profile


Last Name

First Name

Hebrew Name





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.


Grade Entering



Parent Information





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


Emergency Contact 2


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.


 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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