Sign Up - The Shul Bayside

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:			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