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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  
Address  
City State Zip  
  		 Email  

 

Home Phone  

Cell Phone  
 

 Date of Birth [MM/DD/YYYY]  
School  
Grade  

 

 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  
Address  
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
Amount  
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: