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For Your Children CTeen Greenwich

CTeen/CTeen Jr. Registration 2021-2022

For more information, please email Rabbi Boruch Ceitlin, CTeen Director
[email protected]
Teen Information
Teen Full Name*
First NameLast Name
Teen Email*
Teen Phone Number*
Area CodePhone Number

Home Address*

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

School*
Grade*CTeen Jr: 6-8 Grades CTeen: 9th-12th Grade
Birth Date*
MonthDayYear
How would you like us to contact you?*Select all that apply
TextWhat's AppEmail
What Social Media platforms do you use?*Select all that apply
FacebookInstagramNone
Who referred you?If applicable
Parent Information
Parent Full Name*
First NameLast Name
Parent Email*
Parent Phone Number*
Area CodePhone Number
Payment
Annual Membership Fee $120/Year*
$120
Total Due
$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

I would like to receive news and updates by email
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