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CTEEN REGISTRATION 2024-25
Teen's Name
First Name Last Name
Birth Date

Month Day Year
Phone Number
E-mail
Parents Name
First Name Last Name
Parents Phone Number
Parents E-mail
Emergency Contact
Primary Emergency Contact Name:*
First Name Last Name
Phone Number
Relationship to Teen
Secondary Emergency Contact Name:
First Name Last Name
Phone Number
Relationship to Teen
Medical Information
Hospital/Clinic Preference:*
Physician’s Name:*
First Name Last Name
Physician’s Phone Number:*
Insurance Company:
Policy Number:
Allergies/Special Health Considerations:
Authorization:*

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.I give permission for my child to go on field trips. I release Aventura Chabad and individuals from liability in case of accident during activities related to Aventura Chabad, as long as normal safety procedures have been taken.By entering your first and last name below, you electronically acknowledge having read and understood this Agreement and agree to the terms and conditions herein.By entering your first and last name below, you electronically acknowledge having read and understood this Agreement and agree to the terms and conditions herein.
Signature
First Name Last Name
Date

Month Day Year
at Hour Minutes
Early Bird Special

$350
Price

$500

Payment

Credit Card eCheck

Postal / Zip Code

Country

Terms of Agreement (PLEASE READ CAREFULLY-NO EXCEPTIONS)
I understand:*

1. Payment in full is due with application, including all head checks or credit cards.2. Payment is Non-Refundable, for any reason, even if your child does not attend the program.3. Withdrawal of enrollment privileges, for any reason, does not relieve the Undersigned of the responsibility for the payment of the entire financial obligations for the program you enrolled your child in.4. By entering your first and last name below, you electronically acknowledge having read and understood this Agreement and agree to the terms and conditions herein.5. Your first and last name below represents your agreement to all the terms and conditions written above and will serve as your consent to all of the terms and conditions written above.
Signature
First Name Last Name
Date

Month Day Year
at Hour Minutes
I would like to receive news and updates by email
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CTEEN REGISTRATION 2024-25

Emergency Contact

Medical Information

Terms of Agreement (PLEASE READ CAREFULLY-NO EXCEPTIONS)