Join - ChabadWilmette.com

Teen's Name*

First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Teen's Cell*

Area Code Phone Number
Teen's email*
School*
Grade Entering 2024/25*
Previous Jewish Education

YesNo
Where
T-Shirt Size*
Parents Information
Mother's Name*

First Name Last Name
Hebrew Name
Mother's Cell*

Area Code Phone Number
Mother's E-mail
Is mother Jewish?*

YesNo
Father's Name*

First Name Last Name
Father's Hebrew Name
Father's Cell

Area Code Phone Number
Father's E-mail
Is father Jewish?*

YesNo

Address*

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

Home Phone

Area Code Phone Number
General Information
Name & ages of other children
Congregation Membership
Please indicate if there is a conversion or adoption in the family*

YesNo
Please share more information (who, by which officiating Beth Din etc).
Does either parent have any special skill or resource to offer our club?
Emergency Information
Emergency Contact 1*

First Name Last Name
Phone Number*

Area Code Phone Number
Emergency Contact 2*

First Name Last Name
Phone Number*

Area Code Phone Number
Doctor*

First Name Last Name
Phone Number

Area Code Phone Number
Allergies and/or other known conditions we should be aware of
Permissions
*

If parents can not be reached and emergency medical advice is needed, permission is granted to phone my child's doctor. In case of medical emergency requiring immediate emergency care, I authorize transportation to nearest medical facility
*

I, the legal parent/guardian, authorize you and your agents to involve our child in these various trips and activities, direct you to rely upon the registration forms previously tendered for emergency contact persons for the benefit of our child, authorize the administration of any medicines deemed necessary by emergency health professionals in the event of non-availability of parent/guardian, acknowledge that all known allergies or other conditions impacting the health and well being of our child are listed below, and further release the Chabad and its agents from liability arising during the course of these various field trips and activities.
*

I/we understand that my/our child(ren) may be included in photographs and video footage that may be photographed or filmed during CTeen. I authorize CTeen Jr and Chabad of Wilmette to use these photos/videos to promote its programs and services in print, web, and other promotional contexts.
Payment*

$200 - Standard (monthly club) option$750 - Weekly class (includes monthly club)Special arrangment
Total

$0.00

Payment

Credit Card Check or Special Arrangement

Postal / Zip Code

Country

Should be Empty:

Parents Information

General Information

Emergency Information

Permissions