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
2 digit day, 2 digit month, 4 digit yearDate
Current Age
T-shirt Size

Other
Teen's Phone Number
Format: (000) 000-0000.
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.Format: (000) 000-0000.
Mother’s Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
Father's Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Father's Email address
example@example.com
Number to be added to Camp Whatsapp group:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact

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

Payment

Camp fee

8,900.00 INR

Enter coupon

Total

Should be Empty:

CTeen Camp Registration Form 5785 - 2025!

Payment*

Payment