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) Yes! I would like to sign up for the annual CTeen NYC Shabbaton and save 20%! (Early Bird price is $400; Regular $500) Please confirm the total to be charged to your credit card: Name on Card: Card #: Card Type: Select Visa Mastercard American Express Exp. Date: Select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Select 2017 2018 2019 2020 2021 2022 Looking Foward To A Great Year! #CTEENMKE Problems with this form? Please call (414) 228-8000 ext. 205 or e-mail [email protected] This page uses 128 bit SSL encryption to keep your data secure.
