CTeen Registration - chabadofgwinnett.org

Please complete the following form with a parent/guardian. You will only need to fill this out once. Once you have submitted this form, click "yes" when RSVPing for individual events to indicate that we have your form on file.
Parent Information
Parent 1 Name:*
First Name Last Name
Parent 1 E-mail:*
Parent 1 Phone Number:*
Parent 2 Name:*
First Name Last Name
Parent 2 E-mail:*
Parent 2 Phone Number:*
Emergency Contact:*
First Name Last Name
Emergency Contact Phone Number:
Relationship:
Teen's Information
Teen Name:*
First Name Last Name
Birth Date:*

Month Day Year
Hebrew Birth Date (If known):
Teen Phone Number:*

Address:*

School:*
Grade:*
Please let us know if you have any allergies or any other medical concerns we should be aware of:*
Is teen's biological mother Jewish?*

YesNo
Is teen's biological father Jewish?*

YesNo
Have there been any conversions in the family?*

YesNo
If yes, please specify who:
Photography Permissions
I/we understand that my/our child may be included in photographs and video footage that may be photographed during CTeen of Atlanta events/encounters. I authorize CTeen of Atlanta to use these photos/videos to promote its programs and services in print, web and other promotional contexts.
We have read the above statement and agree*

I agree
Teen's Signature*
Parent's Signature*
I would like to receive news and updates by email
Should be Empty:

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Parent Information