Registration - Chabad of Bradenton

Information & Registration
Dates: September 9, October 9, November 7, December 2, January 6, February 1, March 17, April 21, May 29, June 7
Time: 7:00 pm (some times may vary)
Program Fee: $245 per year (includes all trips and programs excluding NY Trip and end year CTeen trip.)
$245
Teen Information
Full Name*
First Name Last Name
Hebrew Name*
Date of Birth*

Month Day Year
E-mail*
Phone Number*

Address*

Address*

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

Postal / Zip Code

Country

Permission is hereby given for Chabad of Badenton & Lakewood Ranch 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
Should be Empty:

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Information & Registration