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of Skokie

ב"ה

Cteen Girls Retreat

January 10-11, 2025

Full Name of teen:*
First Name Last Name
Teen's cell*

Area Code Phone Number
Teen's E-mail*
Current School*
Current Grade*

Address

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

Parent/Guardian*
Prefix First Name Last Name
Parent/Guardian E-mail*
Parent/Guardian Phone Number*

Area Code Phone Number
Any comments about allergies, medications, or other information we need to know?
Registration Fee:*

$200 Full Price$150 SubsidizedCustom
I would like to be a sponsor:

$72$180$300
Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

I agree to indemnify and hold harmless Lubavitch Chabad of Skokie and Skokie Cteen and their employees in case of injury, G-d forbid. I give my child permission to participate in all activities, and for medical treatment to be administered in case of emergency.
Initial here to indicate you have read and agree to these terms:*
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