Printed from ChabadJewishLife.org
Of Merrick-Bellmore

CTeen Registration

CTeen Registration

   CTeen Membership Form

Thank you for taking the time to complete this application and becoming a member of CTeen of Merrick-Bellmore.  

Teen's Information:

First Name  Last Name

Hebrew Name  

Date of Birth  

Home Address

Home Phone   Cell  

Email  

School   Grade  

Best way to contact me is email phonetext facebook

Parent's Information:

Father's Name  cell

Mother's Name  cell

Email 

 Home phone

Home Address 

Payment Options:

Yes, I'd like to join as a Gold Member for $100. (Covers most events, discounts for larger events)

Yes, I'd liketo join as a Classic Member for $36. (Discount for each event)

 Please charge my card in the amount of

Card Type Visa/Master American Express 

 Amount to charge $ 

Card Number   

Expiration Date   

 Permission is hereby given for Chabad of Merrick 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.

Comments:   

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