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of Anne Arundel County

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Registration

Please select:*

I AM A TEEN (this registration is for me) MY TEEN (I am a parent, this registration is for my teen)
Teen's Information
Full Name*

First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

School*
Grade entered in September 2021**
Birth Date*

Month Day Year
What is your preferred method of communication?*

Email Text Message Both
Two friends I would like to refer to CTeen (optional):
Friend 1:

First Name Last Name
Friend 2:

First Name Last Name
Is Your Mom or Dad Jewish?*

Mom Dad Both
How did you hear about CTeen?
Parent's Information
Mother's Full Name*

First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number
Cteen Cares registration $100 (Fees will cover basic expenses for the program such as refreshments, supplies, and discount for the annual Cteen NY Shabbaton and regional trips)
Yes, I look forward to a great year as a CTeen Member:*

CTeen Membership $100 I'd like to donate towards CTeen's wonderful projects
Please accept my donation of:

$
Total

$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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