Cteen Jr. Registration 2019/20 - Lubavitch Chabad of Skokie

Child's Name*

First NameLast Name

Hebrew Name*

Birth Date*

MonthDayYear

Grade for 2019-2020*

6th Grade7th Grade8th Grade

School attending for 2019-2020 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:*

-- All Cteen Junior events are $20/meeting (drop-in price)
-- Cteen Jr. Socials are 6:30-8pm, dinner & activity included
-- Cteen Jewish Essentials are 6:30-7:30pm, dinner and lesson included
-- Sign up for all Cteen Jr. Social & Jewish Essentials for $330 total ($15/meeting)
-- Sign up for all Cteen Jr. Socials for $96 ($16/meeting)

I am paying for:*

All 2019/20 sessions: 16 Jewish Essentials meetings, and 6 Cteen Jr. SocialsAll 2019-20 Socials : 6 sessionsA single Jewish Essentials meeting (please specify date in comments below)A single Cteen Jr. Social (please specify date in comments below)

Please consider taking this opportunity to support the wonderful activities of Skokie Cteen, and enter a donation amount here.

$

Total

$330.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

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*