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Full Name* First Name Last Name Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Parents Information Dads Name* First Name Last Name Jewish* YesNo If Yes* By BirthBy ChoiceNot Moms Name* First Name Last Name Jewish* YesNo If yes* By BirthBy ChoiceNot E-mail* Phone Number Area Code Phone Number Parents Information Membership* $180 As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of CTeen 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 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 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 club use of our personal information and of our child/children at its discretion in pursuit of school activities. 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