Register - ChabadVenetian.com

CTeen Jr. meets Bi-Weekly, 10:00 am - 12:30 pm,
boys and girls grades 7 and 8.
Teen Profile
Teen's Name*

First Name Last Name Hebrew Name
E-mail*
Cell Phone*

Area Code Phone Number
Age*
Birth Date*

Month Day Year
at Hour Minutes
School Attending*
Grade *

Address*

Additional notable Information
Parents Information
Father's Name*

First Name Last Name
Father Cell

Area Code Phone Number
Father's E-mail*
Mother's Name*

First Name Last Name
Mother's Hebrew Name*
Mother Cell

Area Code Phone Number
Mother's E-mail*
Is the natural mother of the child Jewish? *

YesNo
Were there any conversions or adoptions in your family? If Yes, Please describe.*
Emergency Contact Name*
Emergency Contact Number*

Area Code Phone Number
Please list any allergies or health concerns*
My hobbies, talents or interests
Payment
Cost*

$770 per teen (includes supplies/book fee)
Installments

Payment in full upon submissionTwo installments to be paid on Sept. 1 and Jan. 2
Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

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Teen Profile