HS Online Registration

IF ALL YOUR CHILDREN HAVE ATTENDED GROW BEFORE AND THERE IS NO INFORMATION THAT NEEDS UPDATING, PLEASE CLICK HERE FOR THE EXPEDITED CTeen Junior FORM

Number of Children being registered:

Child 1

Name Hebrew Name Last Name

Birth Date & time (for Hebrew Birthday)

Month Day Year

at Hour Minutes

Gender

MaleFemale

Child 2

Name Hebrew Name Last Name

Gender

MaleFemale

Birth Date & time (for Hebrew Birthday)

Month Day Year

at Hour Minutes

Child 3

First Name Hebrew Name Last Name

Gender

MaleFemale

Birth Date & time (for Hebrew Birthday)

Month Day Year

at Hour Minutes

Home Phone Number*

Area Code Phone Number

Address*

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

Mother's info

First Name Last Name

Work Phone

Area Code Phone Number

E-mail Primary email

Cell Phone

Area Code Phone Number

Father's info

First Name Last Name

Work Phone

Area Code Phone Number

E-mail

Cell Phone

Area Code Phone Number

How did you hear of CTeen Junior?

Is the natural mother of the child Jewish?*

YesNo

Are there any conversions or adoptions in the family? (Including Parents, Grandparents, Great -Grandparents etc..)*

YesNo

If yes, please explain

What goals do you have for your child attending CTeen Junior?

Emergency Contact*

First Name Last Name

Phone Number*

Area Code Phone Number

Relationship*

Doctors Name*

First Name Last Name

Doctors Phone Number*

Area Code Phone Number

Does your child(ren) have any allergies or medical conditions.*

If yes please specify which child and what they are.

Permission for emergency medical treatment*

As the parent or legal guardian, I authorize any adult acting on behalf of CTeen Junior 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 Junior personnel will try, but are not required, to communicate with me prior to such treatment.

The tuition for CTeen Junior is $650.00 per year per child plus the $50 registration & book fee. For members it is discounted to $470 plus the $30 registration fee.

Family discounts and scholarships available.

For more information about scholarships or for assistance with a financial plan, please contact Rabbi Pinchas Adler 727 631 7398

Are you a member?*

Choose your plan

Plan A - Pay full today $500, Plan B - Pay $30 Today, and then monthly $52 September - May, Plan C - Payment plan discussed with Rabbi Adler

Choose your plan

Plan A - Pay full today $700, Plan B - Pay $50 Today, and then monthly $72 September - May, Plan C - Payment plan discussed with Rabbi Adler

Payment*

Credit Card Check

Total

$0.00

To find our more about our membership, click here: https://www.yichabad.com/templates/articlecco_cdo/aid/1912924/jewish/Membership.htm

Agreement*

I am signing up my child for CTeen Junior. I give my child permission to attend all trips. I give permission to CTeen Junior to photograph and videotape my children and use the photos and videos for advertising purposes.

Please share any other information you feel is important for CTeen Juniorto be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.

NOTE: if this is your child's first year attending CTeen we will contact you to set up a brief meeting regarding acceptance. Filling out the registration form does not automatically ensure enrollment for first time students. Thank you!

CTeen Junior Registration

1. Child/ren’s Information

2. Parent information

3. Emergency Information

5. Payment Information