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OF ROSLYN

CTeen 2016/17

CTeen 2016/17

REGISTRATION FORM

Registration 2016/17 is now open!


PARTCIPANT INFO
First Name Last Name
Gender Male Female School Attending
Address City
State NY Zip
Home Phone Cell Phone
Email
Allergies Synagogue Affiliation
PARENT INFO
Mom First Name Mom Last name
Mom Cell Number Mom Email

Dad First Name Dad Last name
Dad Cell Number Dad Email
BILLING INFO
Cost Scholarship price *$360.00 Full price $499 Donate *$0.00 Total *$360.00
I would like to help sponsor a teen who lacks the funds to participate

Payment Method
Name on Card Card Number
Exp. Date CVC Number
Address City
State Zip
Please email confirmation to the following email address

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