Cteen Jr Info
Full Name
Address
Cell Number
Email
Facebook Name
Instagram Name
School
Grade
Does your child have any allergies?
Yes
No
If yes, list them here:
Parents
Father's Name
Religion
Occupation
Cell Number
E-mail
Mother's Name
Religion
Occupation
Cell Number
E-mail
Marital Status of Parents
Married
Separated
Divorced
Siblings
Full Name
Age
Full Name
Age
Payment
Payment
Total Amount
0.00
Payment Method
Credit Card Information
Type
Visa
MC
Amex
Discover
Number
Expiration
Code
Use contact info above
Name
Address
Zip
By clicking you will be signing this waiver in which you acknowledge the risks involved in your child's participation in Cteen Jr at Chabad Neshama, you release Chabad Neshama and any staff from liability, authorize emergency medical treatment, grant permission for photo and video use, agree to the program's policies, understand your registration information will be stored online, and confirm your understanding and agreement to these terms.
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