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Teen Membership

CTeen Membership 2020-21

Register up to 3 teens per family per application.
Parents' Information - MOTHER
Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Email*

Address*

Street Address
Apt/Unit No.
City	State
Zip Code	Country

Parents' Information - FATHER
Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Email*
Address*

Same as above Different

Street Address
Apt/Unit No.
City	State
Zip Code	Country

Teen 1 Information
Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Email*
Address*

Lives with Mother Lives with Father
School*
Gender*

Male Female
Date of Birth*

Month Day Year
Time of Birth* Needed to calculate Hebrew Birthday

Hour Minutes
Sweater Size*

Small Medium Large Extra Large
Click here to Register another Teen
Teen 2 Information
Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Email*
Address*

Lives with Mother Lives with Father
School*
Gender*

Male Female
Birth Date*

Month Day Year
Time of Birth* Needed to calculate Hebrew Birthday

Hour Minutes
Sweater Size*

Small Medium Large Extra Large
Click here to Register another Teen
Teen 3 Information
Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Email*
Address*

Lives with Mother Lives with Father
School*
Gender*

Male Female
Birth Date*

Month Day Year
Time of Birth* Needed to calculate Hebrew Birthday

Hour Minutes
Sweater Size*

Small Medium Large Extra Large
Payment
Membership*

$50
Membership*

$100
Membership*

$150
Donation Optional

$50.00 $100.00 $180.00 $500.00 $1000.00
In honor of... In Memory of...
Total

$0.00

Payment*

Credit Card Check

Postal / Zip Code

Country

Waiver*

I/we understand that my/our child may be included in photographs and video footage that may be photographed or filmed during CTeen. I authorize CTeen and Chabad of Contra Costa to use these photos and/or to promote its programs and services in print, web and other contexts.
I would like to receive news and updates by email
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