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Cteen Club registration Form

Cteen Club registration Form

Cteen Club Registration Form

Family Name

First Name

Hebrew Name

Date of Birth Year

Father's Name

Home Phone

Work Phone

Email Address

Cell

Occupation

Home Address

City

Postal Code

Mother's Name

Home Phone (if different from above)

Work Phone

Email Address

Cell

Occupation

Home Address (if different from above)

City

Postal Code

Does your child have any medical conditions, allergies, or special needs we should be aware of? Yes No If yes, please describe them and indicate any precautions or care needed

Billing Information

Fee: $350

10% discount for siblings.

Registration and payment must be submitted by September 30th.

Credit Card

Type of Card

Name on Card

Card Number

Expiration Date Year

cvv security code number

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