Cteen Membership

Address*

Parents Info
Father's Name*
First Name Last Name
Father E-mail*
Father's Cell Number*

Area Code Phone Number
Mother's Name*
First Name Last Name
Full Hebrew Name*
Mother's E-mail*
Mother's Cell *

Area Code Phone Number
Is the teen's mother Jewish?*

Yes, by birthYes, by choiceNo
Is the teen's maternal grandmother Jewish?

Yes, by birthYes, by choiceNo
Are there any conversions or adoptions in the family?*

YesNo
Please explain
I would like to be added to a parents Whatsapp group with all the latest updates*

YesNo
I would like to be contacted about hosting an event during the year*

YesNo
Total amount*

$350

Payment*

Credit Card

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

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Disclaimer

Permission is hereby given for Chabad of Hallandale/SouthBroward 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.
Should be Empty: