CTeen Danville Registration - Chabad of Danville & S. Ramon

CTEEN DANVILLE RSVP

PARENT/GUARDIAN INFO

Full Name*

First Name Last Name

E-mail*

Phone Number*

Are the natural mother and father of teen Jewish?*

YesNo

If not, please explain

Have there been any conversions in the family?*

YesNo

If yes, please explain

TEEN'S INFO

Full Name*

First Name Last Name

E-mail*

Phone Number*

Birth Date*

Month Day Year

School*

Grade*

Address*

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

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

PERMISSIONS AND LIABILITY WAIVER

I/we give permission for the above-mentioned teen to participate in the activities of CTeen Danville 2024-2025. In consideration of the opportunity for my/our child to participate in the activities of CTeen Danville, I/we release CTeen Danville, 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 Danville, 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 Danville. 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 Danville 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 Danville, 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/we have read the above statement and agree:*

I Agree

EMERGENCY CONTACT

Full Name*

First Name Last Name

Phone Number*

Relationship to Teen*

Would you like to make a donation?

Total

$0.00

Payment

Credit Card Zelle

Postal / Zip Code

Country

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