Registration - ChabadFL.org

Tuesday Evening, 7:00-8:30 PM
Teen's Name:*

First Name Last Name
Date of Birth:*

Month Day Year
Teen's Phone Number

Area Code Phone Number (Teen's)
Teen's E-mail:*
Parent's Names:

First Name Last Name
Parent's Phone Number:

Area Code Phone Number (Parent's)
Parent's E-mail:
Emergency Contact
Primary Emergency Contact Name:*

First Name Last Name
Phone Number:*

Area Code Phone Number
Relationship to Child:*
Secondary Emergency Contact Name:

First Name Last Name
Phone Number:

Area Code Phone Number
Relationship to Child:
Medical Information
Hospital/Clinic Preference:*
Physician’s Name:*

First Name Last Name
Physician’s Phone Number:*

Area Code 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. 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 the terms and conditions written above.
Signature:*

First Name Last Name
Date:*


Cteen Prices: (Excluding trips)	Cteen Junior Prices:
$ 400 - Cteen (9th-12th Grade) $360 - Early Bird Special	$ 400 - Cteen Junior (7th-8th Grade) $360 - Early Bird Special

Teen Division:*

Cteen (9th - 12th Grade) Cteen (Early Bird) Cteen Jr (7th - 8th Grade) Cteen Jr (Early Bird)
Total Amount:

$0.00

Payment:*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Payment Options:

Full Payment 2 Payments 3 Payments 6 Payments
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:*
Should be Empty:

Tuesday Evening, 7:00-8:30 PM

Emergency Contact

Medical Information

Terms of Agreement