Cteen Annual Registration School Year 2015-16 Membership is required in order to join monthly meetings and events. Annual Fee: $50 Monthly Events will require a small fee for the cost of that event. Teen's Name Gender Select Male Female Hebrew Name Date of Birth Last Name School Address Grade Select Seventh Eighth City, Zip & State Hebrew Birthday Teen's Cell Synagogue Teen's Email Biological Mother Select Is Jewish Is Not Jewish Emergency Contact Emergency Contact Phone Mother's Name Father's Name Mother's Phone Father's Phone Mother's Email Father's Email Payment Method Select Visa Mastercard American Express Check is in the mail Card Number Expiration Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 CVV Code Cardholder's Name Billing Zip Total Amount Comments Check can be mailed to Chabad of S. Clemente • 1306 North El Camino Real • S. Clemente, CA 92672
