CTeen Junior Registration Returning Children - Young Israel

1. Child/ren’s Information
Number of children being registered:*
Child 1
Name Hebrew Name Last Name
Birth Date*

Month Day Year
Child 2
Name Hebrew Name Last Name
Birth Date*

Month Day Year
Child 3
First Name Hebrew Name Last Name
Birth Date*

Month Day Year
2. Parent information
Mother's info
First Name Last Name
E-mail* Primary email
Cell Phone

Area Code Phone Number
Father's info
First Name Last Name
E-mail
Cell Phone

Area Code Phone Number
What goals do you have for your child attending CTeen Junior?
3. Emergency Information
Emergency Contact*
First Name Last Name
Phone Number*

Area Code Phone Number
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.
4. Payment Information
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 $700, Plan B - Pay $50 Today, and then monthly $72 September - May, Plan C - Payment plan discussed with Rabbi Adler
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

Payment*

Credit Card Check

Total

$0.00
Agreement*

I am signing up my child for CTeen Junior . Please charge my card the registration fee or send me a invoice today. 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 Junior to be aware of. This can include exceptional behavior, concerns, particular activities, family relationships etc.
Should be Empty:

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1. Child/ren’s Information

2. Parent information

3. Emergency Information

4. Payment Information