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North Miami Beach

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CTeen Registration

CTeen Registration
Student's Name*

First Name Last Name
Cell
eMail
Birth Date*

Month Day Year
School*
Other Clubs You're Involved With
Previous Jewish Education (if any)
Grade entering*

Address

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

Additional notable Information
Parents Information
Father's Name

First Name Last Name
Father Cell

Area Code Phone Number
Father eMail
Mother's Name

First Name Last Name
Mother Cell

Area Code Phone Number
Mother eMail
Are Your Parents Jewish?
No Charge For Students To Join!
There is no charge to join the CTeen Club at your school. However, donations or sponsorship of any amount to help cover the cost is greatly appreciated!
$540 Sponsor Teen for Full Year $1,080 Sponsor 2 Teens for Full Year $1,800 Sponsor 4 Teens for Full Year $18,000 Sponsor Teen Programming at a Public High School for Half Year $36,000 Sponsor Teen Programming at a Public High School for a full Year Any Amount of Sponsorship is Greatly Appreciated -
Total

$0.00 USD
Amounts

$540 USD $1080 USD $1800 USD $18000 USD $36000 USD

Payment

Credit Card Other

Postal / Zip Code

Country

Should be Empty:

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