Cteen Jr. Registration 2018/19 - Lubavitch Chabad of Skokie

Child's Name*

First NameLast Name

Hebrew Name*

Birth Date*

MonthDayYear

Grade for 2018-2019*

6th Grade7th Grade8th Grade

School attending for 2018-2019 year*

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

Mother's Name:*

First NameLast Name

Mother's Cell:*

Area CodePhone Number

Home Phone:*

Area CodePhone Number

Father's Name:*

First NameLast Name

Father's Cell:*

Area CodePhone Number

Address:*

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

Mother's E-mail:*

Father's E-mail:*

-- Cteen Jewish Essentials are $20/meeting (drop-in price) or $350 for the full year.
-- Cteen Jr. Socials are $15/meeting (drop-in price) or $75 for all 6 meetings.
-- Sign up for all Cteen Jr. Social & Jewish Essentials for $400 total.

I am paying for:*

Total

$0.00

Comments:

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Skokie Cteen 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, Skokie Chabad Hebrew School personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities. I allow my child to be photographed while participating in Skokie Cteen activities and acknowledge that these pictures may be used for marketing purposes.

*

I Accept

Initials*