CTEEN REGISTRATION

Name *

First Name Last Name

Birth Date*

Month Day Year

Phone Number*

Area Code Phone Number

E-mail*

School*

Grade*

Address

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

Please write Teen's Hebrew name if you know it.

Please let us know about any allergies or medical concerns we should be aware of.*

Please let us know about any dietary restrictions or prefernces we should be aware of.*

Parent / Guardian #1 Full Name

First Name Last Name

Parent / Guardian #1 E-mail

Parent / Guardian #1 Phone Number

Area Code Phone Number

Parent / Guardian #2 Full Name

First Name Last Name

Parent / Guardian #2 E-mail

Parent / Guardian #2 Phone Number

Area Code Phone Number

Full Name*

First Name Last Name

Phone Number*

Area Code Phone Number

E-mail*

Relationship to teen*

I would like to be involved in Cteen leadership

School club leaderCteen leadership boardCteen newsletter editorial board

CTeen enrollment is required for all Teens who will participate in any CtTeen events or programs throughout the year. CTeen enrollment details will not be discussed or affect a Teens treatment at CTeen events and programs.

Choose your enrollment:*

Gold member volunteer: Updates & notifications for all events and programming. Community services logging and tracking. Birthday gift package. Pre-holiday gift packages.Platinum member volunteer: Welcome package with swag. 10 percent off all local events.Updates & notifications for all events and programming. Community services logging and tracking. Birthday gift package. Pre-holiday gift packages.Diamond memeber volunteer: All local events FREE. Welcome package with swag. 10 percent off ALL REGIONAL EVENTS (including Shabbatons!).Updates & notifications for all events and programming. Community services logging and tracking. Birthday gift package. Pre-holiday gift packages.

Total

$0.00

Payment

Credit Card Other

Postal / Zip Code

Country

I/we give permission for the above-mentioned teen to participate in the activities of CTeen of Hunterdon County. In consideration of the opportunity of my/our child to participate in the activities of CTeen of Hunterdon County, I/we release CTeen of Hunterdon County, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for any loss or injury to my/our child arising from my/our child’s participation in the activities; and I/we agree to indemnify and hold forever harmless CTeen of Hunterdon County, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for loss or injury to my/our child arising from activities of the CTeen of Hunterdon County. I/we understand that during events participants will be following current CDC guidelines in regards to the Covid-19 pandemic; I/we will not hold CTeen of Hunterdon County responsible if the above-mentioned teen contracts Covid-19 while attending an event. As the parent(s) or legal guardian(s) of the above-mentioned teen participant, I/we give permission for CTeen of Hunterdon County, its agents, staff, and volunteers to obtain urgent or emergency medical care for my/our child, and I/we authorize health care providers to render such care as may be necessary. It is understood that reasonable efforts will be made to contact me/us prior to obtaining such care, but I/we authorize such care whether I/we are contacted or not, and I/we agree to be financially responsible for such care. I agree to allow Cteen of Hunterdon and Chabad of Hunterdon to utilize media of my child on social platforms and for marketing purposes.

*

I agree

Comments/notes

TEEN INFO

PARENT / GUARDIAN INFO

EMERGENCY CONTACT

Leadership

MEMBERSHIP

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