New Customer Registration Form

CTeen Camp Registration Form 5785 - 2025!

Please fill out the following form accurately and completely. This information will help us ensure a safe and enjoyable week for all participants.

Trip Details:

- Mumbai Madness Dates: May 20-22

- Shabbat Gateaway Dates: May 23-25
Teen information:
Name*

First NameMiddle NameLast Name
Teen's Date of Birth*

DayMonthYear
Date
Current Age*
T-shirt Size*

Extra SmallSmallMediumLargeExtra LargeXX LargeXXX LargeOther
Teen's Phone Number*
Teens email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My Jewish Background (Were there any Jewish conversions in your parents / grandparents family?) If yes, please specify.
My Jewish Background*
Family Information
Mother’s Full name*
Mother’s Contact number*
Please enter a valid phone number.
Mother’s Birthday

MonthDayYear
Date
Mother’s surname before marriage*
Mother’s Email address*
example@example.com
Parents relationship**
Father's Full name*
Father's Contact number*
Please enter a valid phone number.
Father's Birthday

MonthDayYear
Date
Father's Email address*
example@example.com
Number to be added to Camp Whatsapp group:
Please enter a valid phone number.
Emergency contact

FatherMotherOther - Name, Contact, Connection to teen.
Any important information we should know about the family?
Medical Information:
Allergies (if any):
Current Medications (if any):
Chronic Illnesses/Conditions (if any):
Dietary Restrictions:
Any Recent Injuries/Surgeries:
Blood Type (if known):
Any important information we should know about the teens Emotional, Social or Physical health?
Health Declaration:
Signature (Teen):*

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Parent/Guardian Consent:
[Parent/Guardian's Name]*
Signature (Parent/Guardian):*

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Payment*

Camp fee

8,900.00INR

Enter coupon

Total

0.00INR

Should be Empty:

CTeen Camp Registration Form 5785 - 2025!