Register - Chabad at Wiregrass

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I am a Teen RegsiteringI am a Parent registering my teen
Full Name*
First NameLast Name
E-mail*
Phone Number*
Area CodePhone Number
Entering Grade*
Birthdate*
MonthDayYear
I would like to register for the following:
$18 –Membership (There will be a separate fee for trips)$72 – Membership & All Trips ( Excluding NYC trip)$180 – Sponsor – Covers Membership & All Trips ( Excluding NYC trip)
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*
MonthDayYear
Total
$0.00

Payment

Credit Card

Billing Address

Street Address

Street Address Line 2

City

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