Printed from ChabadVA.org

Registration Form

Registration Form

 

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Chabad Lubavitch of Northern Virginia

CTeen Registration Form  

Dear Teen,  

Thank you for taking the time to complete this application and becoming a member of CTeen of Fairfax.  

Become a CTEEN Member and enjoy all these benefits:            

  • Covers all regular events, discounts for larger events and trips
  • Cteen Sunday Night Dinner's 
  • A membership certificate
  • Exclusive events
  • And much more…


Looking forward to an awesome fun-filled year together!

Teen Information
First Name  
Last Name  
Hebrew Name  
Address  
City State Zip  
  
Email  

 

Home Phone  

Cell Phone  
 

Date of Birth [MM/DD/YYYY]  
School  
Grade  

 

 Best way to contact me  
Email Phone  
Text Facebook

 
Parent Information
Father's Name  
 Father's Cell 
 
Father's Email  
Mother's Name  
Mother's Cell  
Mother's Email  
Home Phone  
Address  
Emergency Contact
 

 

 

Payment Information
I will send in a check in the amount of $360
I will send in a check in the amount of $180 today and $180 on January 1st, 2015
Please charge my credit card in the amount of $360
Please charge my card $180 today and $180 on January 1st, 2015
Amount  
Card Type  
Card Number  
Expiration Month  
Expiration Year  
Cvv Code  

 

 

 

 

Permission is hereby given for Chabad Lubavitch of Northern Virginia CTeen to use inpromoting CTeen and in other ventures directly relating to CTeen/Chabad (i) digital, photographic, video, and audio images or likenesses of teen member; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by the teen member or originating from CTeen or from a CTeen related activity. Permission is given to my child/ren to participate in all Cteen activities.

Signature or Parent/Guardian:  Date:   

 

 

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WELCOME TO CTEEN - THE COOLEST PLACE FOR JEWISH TEENS

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