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CORAL SPRINGS

ב"ה

Register

Teen Information
Full Name*

First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Home Phone*

Area Code Phone Number
Cell Phone*

Area Code Phone Number

Address*

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

School Attending in 2024-25*
Grade*
E-mail*
Best way to contact me is: Check 2 that apply

CallTextWhatsappFacebookEmail
Parents Information
Mother's Name*

First Name Last Name
Mother's Cell*

Area Code Phone Number
E-mail*

Address If different than teen

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

Father's Name*

First Name Last Name
Father's Cell*

Area Code Phone Number
E-mail*

Address If different than mother's

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

Emergency Contact
Full Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Relation to Teen*
C-TEEN ORANGE & BLUE KICK OFF PARTY

SUNDAY, SEPT. 15 - 5:30 PM
Teen listed above will be attending party

YesNo
Annual membership for CTeen is $360

Become a C-Teen Member and enjoy all these benefits:
- Free admission to all in-house programs
- Free Awesome CTeen Gear
- Big Discount for all trips
- Opportunity and Discount to participate in the Regional CTeen Shabbaton and trips
- Opportunity and Discount to participate in the International CTeen Shabbaton in NYC
For scholarships or payment plans, please contact Rabbi Shaya @ 954-899-6676.
I hereby give permission:*

For Coral Springs CTeen Chapter to use digital, photographic, video, and audio images or likenesses of teen member in promoting CTeen and in other ventures directly relating to CTeen/Chabad.
Payment Information

There is a $360 annual fee. For scholarships or payment plans, please contact Rabbi Shaya @ 954-899-6676.
Teen Registration:
Total

$0.00

Payment

Credit Card eCheck Check

Postal / Zip Code

Country

Should be Empty:

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