Registration CTeen

Enrollment in CTeen costs $250 for the academic year.

If any question is not applicable, please write N/A

Father's Name*

First NameLast Name

Father's Cell*

Area CodePhone Number

Father's Email*

Mother's Name*

First NameLast Name

Mother's Cell*

Area CodePhone Number

Mother's Email*

Do Parents Live Together?*

YesNo

Address*

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

Father's Address*

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

Mother's Address*

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

Are there any conversions or adoptions in the family?

Mother*

YesNo

Maternal Grandmother*

YesNo

Maternal Grandfather*

YesNo

Father*

YesNo

Paternal Grandmother*

YesNo

Paternal Grandfather*

YesNo

Please provide further details about conversions and/or adoptions in the family.

Are the biological parents of the child/ren Jewish?

Father*

YesNo

Mother*

YesNo

Full Name*

First NameLast Name

Program:*

CTeen (Grades 9-12)

Hebrew Name

Birth Date*

MonthDayYear

Age*

School*

Teen's E-mail*

Teen's Cell #*

Area CodePhone Number

Is your teen attending another youth group, or have they attended another youth group in the past? If yes, where?

Waiver

By checking here, I hereby permit my child/ren to participate in all CTeen activities and trips, on and beyond the Chabad campus. In case of an emergency, I hereby authorize the Chabad of Kendall, it's staff and/or representatives to have my child given proper medical attention. I authorize Chabad of Kendall to use photographs of my child/ren during activities and trips in CTeen promotional material.

Total

$0.00

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

I would like to receive news and updates by email

Registration CTeen

Parents Information

Teen Information

Payment