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Chabad Lubavitch of Alexandria-Arlington
CTeen Registration Form 

Dear Teen, 

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

Become a CTeeN Member and enjoy all these benefits:            

  • Covers all events, discounts for larger events and trips
  • Awesome CTeen Gear
  • 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 
 
Payment Information
I will send in a check in the amount of $180 
Please charge my credit card in the amount of $180
Amount 
Card Type 
Card Number 
Expiration Month 
Expiration Year 
Cvv Code 

Permission is hereby given for Chabad Lubavitch of Alexandria-Arlington CTeen to use in promoting CTeen and in other ventures directly relating to CTeen/Chabad (i) digital, photographic, video, and audio images or likenesses of teen member; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by the teen member or originating from CTeen or from a CTeen related activity.

Signature or Parent/Guardian:  Date: