TEEN REGISTRATION

First Name

Last Name

Teen's  Address City, State, Zip
Teen's Cell Teen's E-mail 
Teen's Gender Male Female

Grade and School

Allergies D.O.B.
How Did You Hear About C-Teen? Why Do You Want To Be A Part Of C-Teen
PARENT INFO
Father's Name Father's Cell
Father's E-Mail Mother's Name
Mother's Cell Mother's E-mail
PAYMENT INFO
  $36 - Annual CTeen Membership Fee $36

NYC Shabbaton 2017 dates TBA (Optional)

Total To Charge:
Name on Card:  Card Number: 
         
Card Type:  Exp. Date:  
Thank You For Your Registration! Looking Forward To A Great Year! #CTEEN MKE

 

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