Registration - Chabad of Bradenton

INFORMATION & REGISTRATION
Dates: September 5, October 3, November 3, December 5, January 16, February 11, March 19, April 16, May 10, June 3
Time: 7:00 pm (some times may vary)
Program Fee: $200 per year (includes all trips and programs excluding NY Trip and end year CTeen trip.)
PARENT'S INFORMATION
Father's Full Name*
First Name Last Name
E-mail*
Mobile Number
Mother's Full Name*
First Name Last Name
E-mail*
Mobile 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*
Should be Empty:

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INFORMATION & REGISTRATION