Teen Profile 1
Name
Last
Hebrew Name
DOB
School
Grade Entering
Email
T-Shirt Size
Teen Profile 2
Name
Last
Hebrew Name
DOB
School
Grade Entering
Email
T-Shirt Size

Teen Profile 3
Name
Last
Hebrew Name
DOB
School
Email
T-Shirt Size

Parent Information
Father's Name
Phone
Mother's Name
Phone
Address
City
State
Zip
Email Address


Emergency Information
Emergency Contact 1
Phone
Emergency Contact 2
Phone

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.


As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Chabad to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all school activities, allow my child to be photographed while participating in Chabad activities and that these pictures may be used for marketing purposes.

.

I Accept

Name:
Initials:

We look forward to a wonderful year of learning and growing