For teens in grades 6-7: 1. Child/ren’s Information Child 1* Name Hebrew Name Last Name Birth Date & time (for Hebrew Birthday)* Month Day Year at 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM Gender* MaleFemale Child 2 Name Hebrew Name Last Name Gender MaleFemale Birth Date & time (for Hebrew Birthday) Month Day Year Child 3 First Name Hebrew Name Last Name Gender MaleFemale Birth Date & time (for Hebrew Birthday) Month Day Year at 1 2 3 4 5 6 7 8 9 10 11 12 Hour 00 10 20 30 40 50 Minutes AM PM 2. Parent information Home Phone Number* Area Code Phone Number Address* Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other 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 Jr.? Mailer Email Facebook Newspaper Ad Internet Search Attended Previously Friend Other 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 Jr.? 3. Emergency Information 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 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. 4. Payment Information The tuition for CTeen Jr. is $300.00 per year per child. Receive a $20 discount when paying in full or make monthly payments of $33.50 from September - May. For more information about scholarships or for assistance with a financial plan, please contact Rabbi Pinchas Adler 727 631 7398 Payment Options* Plan A: I will pay the entire amount in full.To do so, please submit a check or include your credit card information below.Plan B: I will pay the annual tuition on a monthly basis by check. I will send in checks of $33.50 each, September through May. All checks must be submitted on the first CTeen Jr. of the month.Plan C: I will pay the annual tuition on a monthly basis by credit card. Your card will be billed $33.50 monthly September through May. To do so please include your credit card number and expiration date at the bottom of this page. Credit cards will be charged on the first of the month unless otherwise indicated.Payment plan discussed with Rabbi Pinchas Total $0.00 Payment* Credit Card Paypal Check Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Expiration Month 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Expiration Year Paypal has been selected. Payment will take place on the next page. Please write the check out to Chabad of Pinellas County Agreement* I am signing up my child for CTeen Jr. I give my child permission to attend all trips. I give permission to CTeen Jr. 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 Jr. to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc. Should be Empty: Submit This page uses TLS encryption to keep your data secure.