CTeen Registration Form  

Dear Teen,  

Thank you for taking the time to complete this application and becoming a member of CTeen of Fairfax.  

Become a CTEEN Member and enjoy all these benefits:            

  • Covers all regular events, discounts for larger events and trips
  • Cteen Sunday Night Dinner's 
  • Game Room / Homework Nights
  • Friday Night Dinners 
  • A membership certificate
  • Exclusive events
  • And much more…

Looking forward to an awesome fun-filled year together!

Teen Information
First Name  
Last Name  
Hebrew Name  
City State Zip  


Home Phone  

Cell Phone  

Date of Birth [MM/DD/YYYY]  


 Best way to contact me  
Email Phone  
Text Facebook

Parent Information
Father's Name  
 Father's Cell 
Father's Email  
Mother's Name  
Mother's Cell  
Mother's Email  
Home Phone  
Emergency Contact


      Mother is  Jewish     Converted  (check all that apply)


Payment Information
I will send in a check in the amount of $520 
I will send in a check in the amount of $260 today and $260 on January 1st, 2020 
Please charge my credit card in the amount of $520 
Please divide my payments over the next 12 months
Card Type  
Card Number  
Expiration Month  
Expiration Year  
Cvv Code  





Permission is given to my child/ren to participate in all Cteen activities.

Signature or Parent/Guardian:  Date: