Register - ChabadatWiregrass.com

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I am a Teen RegsiteringI am a Parent registering my teen
Full Name of TEEN*

First Name Last Name
E-mail Of Teen*
Phone Number Of teen*

Area Code Phone Number
Entering Grade*
Birthdate*

Month Day Year
I would like to register for the following:*

CTeen JLI$250 - Covers all trips for the year (except NYC & End of Year Trip)Cteen Membership in 5 payments of $50
Photo/Video Release
Permission is hereby given for Chabad at Wiregrass 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.
Initials:*
Date*

Month Day Year
Total

$0.00

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

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Country

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