Clone of Teen Info Form

Teen Information Form & Permissions/Liability Waiver
Please complete the following form with a parent/guardian. You only need to fill this out once per school year.
Teen's Information
Teen's First Name
Teen's Last Name
Gender
Teen's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Teen's Date of Birth

MonthDayYear
Date
Hebrew Birthday (If known)
Home Address
Street Address
City
State
Zip Code
School
Grade
Please let us know if you have any allergies or any other medical concerns we should be aware of
Is teen's biological mother Jewish?
Is teen's biological father Jewish?
Have there been any conversions in the family?
If yes, please specify who:
If yes, in which Beit Din was the conversion?
Parent's Information
Parent 1 Name

First NameLast Name
Parent 1 Email Address
example@example.com
Parent 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Name

First NameLast Name
Parent 2 Email Address
example@example.com
Parent 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship To Teen
I/we hereby authorize my/our child to participate in trips conducted by CTeen of Atlanta.
Permissions and Liability Waiver
I/we give permission for the above mentioned teen to participate in the activities of CTeen of Atlanta 2026-2027. In consideration of the opportunity of my/our child to participate in the activities of CTeen of Atlanta, I/we release CTeen of Atlanta, 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 of Atlanta, 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 of Atlanta. As the parent(s) or legal guardian(s) of above mentioned teen participant, I/we give permission for CTeen of Atlanta, 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
Photography Permissions
I/we understand that my/our child may be included in photographs and video footage that may be photographed during CTeen of Atlanta events/encounters. I authorize CTeen of Atlanta to use these photos/videos to promote its programs and services in print, web, and other promotional contexts.
I/we have read the above statement and agree
Teen's Signature
Parent's Signature
Should be Empty:

Teen Information Form & Permissions/Liability Waiver

Teen's Information

Parent's Information

Permissions and Liability Waiver

Photography Permissions