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TEEN REGISTRATION

First Name

Last Name

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

Grade & School

Allergies D.O.B.
How Did You Hear About C-Teen? Tell Us Why 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 C-Teen Registration Fee
 

NYC Shabbaton 2017 dates TBA (Optional)

Please confirm the total to be charged to your credit card:
Name on Card:  Card #: 
Card Type:  Exp. Date:    
Looking Foward To A Great Year! #CTEENMKE
 

 
   

Problems with this form?  Please call (414) 228-8000 ext. 205 or e-mail misia@shulcenter.org

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