CTeen JR - Registration

Full Name*

First Name Last Name

Birth Date*

Month Day Year

Parents Information

Dads Name*

First Name Last Name

Jewish*

If yes *

Moms Name

First Name Last Name

Jewish*

If Yes*

E-mail*

Phone Number

Area Code Phone Number

Address*

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

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/our child, I/we 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/us prior to such treatment. I/we hereby give permission for my/our child to participate in all school activities, join in class and school trips on and beyond school properties and allow my/our child to be photographed while participating in CTeen JR activities. I/we also understand that all liability and costs resulting from damage to property and/or personal injury caused or attributable to my/our child/children will be my/our responsibility and I/we agree to fully indemnify and save Chabad Russian Center and it’s associates, teachers and agents harmless therefrom. I/we consent to Sunny Isles Beach CTeen JR club use of our personal information and of our child/children at its discretion in pursuit of school activities.

Initial*

Date*

Registration

Does not include end year full day trip. Members will receive an exclusive discount on year end trip.

Early Bird Discound $50 - ENDS JULY 11th.

Registration*

$450 - please charge me the full amount today. -$50 (EB Discount)$450 - please charge me in two installments - Now and January -$50 (EB Discount)

Total

$0.00

Payment*

Credit Card Paypal Other

Postal / Zip Code

Country

CTeen JR - Registration

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