Printed from ChabadofVenice.com

OF VENICE & NORTH PORT

Registration

Information & Registration:
Dates: September 22, November 3, December 13, January 19, February 27, March 8, April 5, May 8, June 7
Time: Times Vary
Program Fee: $180 per year (includes all trips and programs excluding NY Trip and partial Busch Gardens)
Teen Information:
Full Name:*
First NameLast Name
E-mail:*
Cell Phone Number:*
Area CodePhone Number
Home Phone Number:
Area CodePhone Number

Address:*

Street Address
Street Address Line 2
City	State / Province
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MonthDayYear
School Currently Attending:
Grade:
Best form of Contact:
Parent's Information:
Father's Name:
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Mother's Name:
E-mail:
Cell Phone Number:
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Address:

Street Address
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Home Phone Number:
Area CodePhone Number
*
CTeen Sign Up
Total
$180.00

Payment

Credit Card

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Name on Card
Expiration Month	Expiration Year

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Permission is hereby given for Chabad of Venice CTeen to use in promoting 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.
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