Information

Teen's Last Name *

Teen Information

Teen's First Name *

Please be sure to write your FULL street address and apartment number if applicable

Street Address *

Supplemental Address

City *

State *

Postal Code *

Country *

Gender *

Female Male

Teen's Birth Date *

Birth Date Before Sunset

Yes

No

Unknown

Grade Entering *

Teen's Email

Teen Cell

Emergency Contact 1 *

Emergency Contact 1 Phone *

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. *

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of 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, CTeen 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, join in class and school trips on and beyond school properties and allow my child to be photographed while participating in CTeen activities and that these pictures may be used for marketing purposes. By submitting this form I acknowledge and agree to the terms and conditions

I Accept *

.

Name

Initial *

CHABAD OF STAMFORD - JEWISH CENTER FOR LIFE AND LEARNING