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.
| Gender | |||
| School | |||
| Address | Grade | ||
| City, Zip & State | Hebrew Birthday | ||
| Teen's Cell | Synagogue | ||
| Teen's Email | Biological Mother | ||
| 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 | Card Number | ||
| Expiration | 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 | |||