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Register - CTeen Jr. - Hebrew School

Register - CTeen Jr. - Hebrew School

Register Online

Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, feel free to call our director Sara Bluming at 240-621-0770 or email

Teen Profile
Last Name
First Name
Hebrew Name
Time of Birth - In Judaism the day begins at nightfall, so in order to determine the exact date of your Jewish birthday we need to know what time of day you were born.
Grade Entering
Parent Information
Father's Name
Father's Occupation
Father's Cell
Father's Email
Mother's Name
Mother's Occupation
Maternal Grandmother born Jewish?
Mother born Jewish? Converted by whom?
Mother's Cell
Mother's Email
Emergency Information
Emergency Contact 1
Emergency Contact 2
Doctor's Name
Doctor's Phone Number
Medical Insurance Company
Policy Number

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.

Registration Payment Agreement
Tuition for the year, per child: $850

Method of Registration payment:

Credit Card (form below)
Check (Please mail checks to Chabad of Potomac, attn: Mrs. Sara Bluming, director, 11826 Seven Locks Rd, Potomac MD 20854 )

Registration Payment
CC Type   Card Number
Billing Address   City, State, Zip
CVV   Exp Date

Total Registration Cost:

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of CTeen Jr. 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, CTeen Jr. 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 activities, join in trips on and beyond school properties and allow my child to be photographed while participating in CTeen Jr. activities and that these pictures may be used for marketing purposes.

I Accept
I grant my child permission to join all Cteen Jr. trips and transportation to trips.

Name: Initials: Date:


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