Chabad Lubavitch of Northern Virginia

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 
  • 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



Payment Information
I will send in a check in the amount of $360
I will send in a check in the amount of $180 today and $180 on January 1st, 2015
Please charge my credit card in the amount of $360
Please charge my card $180 today and $180 on January 1st, 2015
Card Type  
Card Number  
Expiration Month  
Expiration Year  
Cvv Code  





Permission is hereby given for Chabad Lubavitch of Northern Virginia CTeen to use inpromoting 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. Permission is given to my child/ren to participate in all Cteen activities.

Signature or Parent/Guardian:  Date: