Printed from ChabadofVenice.com

OF VENICE & NORTH PORT

Registration

Information & Registration:
Dates: TBA
Time: varying
Program Fee: $180 per year (excludes regional trips and NY trip)
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
Postal / Zip Code	Country

Hebrew Name:
Birth Date:
MonthDayYear
School Currently Attending:
Grade:
Best form of Contact:
Parent's Information:
Father's Name:
E-mail:
Cell Phone Number:
Area CodePhone Number
Mother's Name:
E-mail:
Cell Phone Number:
Area CodePhone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number:
Area CodePhone Number
*
CTeen Sign Up
Total
$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

*
Permission is hereby given for Chabad of Venice & North Port 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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