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 123456789101112 Hour001020304050 MinutesAMPM 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 123456789101112 Hour001020304050 MinutesAMPM 2. Parent information Home Phone Number* Area Code Phone Number Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther 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.? MailerEmailFacebookNewspaper AdInternet SearchAttended PreviouslyFriendOther 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 Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration YearPaypal 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.
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