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If you encounter any difficulties whilst filling in the form,
Please contact Rabbi Shmulik Cohen on: 07969 765 874

 

 Teen's Info

First Name	Last Name

Mobile Number	Email
School & Grade	DOB
	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November  Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  Year 2002 2001 2000 1999 1998 1997 1996 1995
Sweatshirt Size
Small Medium Large XL XXL	Gender:     Boy    Girl

  
 

 Parent/Guardian Info

 Parent 1 

First Name	Last Name
Mobile	Home
Email	Work
Home Address

                                      

 Parent 2

First Name	Last Name
Mobile	Home
Email	Work
Home Address

     
 

 Emergency Contact Info

Name	Relationship
Contact Number	Alternative

         
      

 Medical Info

Name of primary treating physician:

Contact number of primary treating physician:

Allergies (including medications teen can NOT take)/Special Health Concerns:

  
 

 Authorization to obtain Emergency Medical Care

As the parent(s) or legal guardian(s) of  (name of teen), I/we give permission for CTeen, 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.  Digital Signature: Type your name  Relationship To Child:

 Travel Insurance

 If you don't have travel Insurance, you can purchase one now by clicking here.
(Departing 26 February - Returning 2 March. Ensure you chose the option to include USA) 

Medical Insurance Company:

Level of Coverage

Policy Number:

Medical Insurance Phone Number:

        
 

 Permission & Liability Disclaimer

I/we give permission for  (name of teen) to participate in the activities and trips of CTeen’s International Teen Shabbaton. In consideration of the opportunity of my/our child to participate in the activities of CTeen’s International Teen Shabbaton, I/we release CTeen, 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 of the International Teen Shabbaton; and I/we agree to indemnify and hold forever harmless CTeen, 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 International Teen Shabbaton or resulting from traveling to or from the activities.  Digital Signature: Type your name  Relationship To Child:

 Passport Information 

 Please ensure that all details are filled-out precisely as they are in the passport

First Name
Last Name
Passport Number
Valid From
Expiry Date
Nationality
Country of Issue

      

 ESTA Visa Waiver: 

International travelers who are seeking to travel to the United States under the Visa Waiver Program (VWP) are now subject to enhanced security requirements and will be required to pay an administrative fee.

Please ensure that you have a valid visitor's visa or an ESTA.

To apply for an ESTA, please use the following link: https://esta.cbp.dhs.gov

Please note: only fields marked with a red asterisk are mandatory.

If you have already applied for an ESTA in the past, click here for information on the ESTA's length of approval. 

 
 

 Photo Permission

I authorize CTeen to use these photos/videos to promote its programs and services in print, web, and other promotional contexts. 

Digital Signature: Type your name	Relationship To Child:

  
 

 Code of Conduct

 I have read, understood and agree to fully comply with the CTeen Shabbaton Code of Conduct.

Digital Signature: Type your name
Parent:	Teen:

     
 

 Notes 

 Comments / Questions / Suggestions / Blessings...

 

 
 

 Payment

As the cost of the Shabbaton is majorly reduced please consider helping out by donating generously.

£150 Transportation

£250 Activities, Accommodation & Meals

£450 Air Fare

£100 Registration 

 £950 TOTAL 

£499 - All inclusive!

 Payment must be done separately - either by BACS or by sending a cheque (details bellow)