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Youth & Teen Programs

Registration CTeen & CTeen Junior

Parents Information
If any question is not applicable, please write N/A
Father's Name*
First NameLast Name
Father's Cell*
Area CodePhone Number
Father's Email*
Mother's Name*
First NameLast Name
Mother's Cell*
Area CodePhone Number
Mother's Email*
Do Parents Live Together?*
YesNo

Address*

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

Father's Address*

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

Mother's Address*

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

Are there any conversions or adoptions in the family?
Mother*
YesNo
Maternal Grandmother*
YesNo
Maternal Grandfather*
YesNo
Father*
YesNo
Paternal Grandmother*
YesNo
Paternal Grandfather*
YesNo
Please provide further details about conversions and/or adoptions in the family.
Are the biological parents of the child/ren Jewish?
Father*
YesNo
Mother*
YesNo
Teen Information
Full Name*
First NameLast Name
Please select the program this teen will be joining*
CTeen Junior (Grades 6-8)CTeen (Grades 9-12)
Hebrew Name
Birth Date*
MonthDayYear
Age*
School*
Teen's E-mail*
Teen's Cell #*
Area CodePhone Number
Is your teen attending another youth group, or have they attended another youth group in the past? If yes, where?
Payment
Total
$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

Should be Empty:

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