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TEEN REGISTRATION |
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First Name
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Last Name |
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Teen's Address |
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City, State, Zip |
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Teen's Cell |
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Teen's E-mail |
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Teen's Gender |
Male Female |
Grade and School
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Allergies |
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D.O.B. |
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How Did You Hear About C-Teen? |
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Why Do You Want To Be A Part Of C-Teen |
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PARENT INFO |
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Father's Name |
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Father's Cell |
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Father's E-Mail |
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Mother's Name |
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Mother's Cell |
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Mother's E-mail |
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PAYMENT INFO |
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$36 - Annual CTeen Membership Fee $36 |
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NYC Shabbaton 2017 dates TBA (Optional)
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Total To Charge: |
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Name on Card: |
Card Number:
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Card Type: |
Exp. Date: |
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Thank You For Your Registration! Looking Forward To A Great Year! #CTEEN MKE |
