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CTeen JR Registration

Cteen Jr Registration
Teen's Name*

First Name Last Name
Birth Date*

Month Day Year
School*
Grade entering*
Teen's Email Address
Teen's Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Additional notable Information
Parents Information
Father's Name*

First Name Last Name
E-mail
Father Cell

Area Code Phone Number
Mother's Name*

First Name Last Name
E-mail
Mother Cell

Area Code Phone Number
Has there been any adoptions or conversions in the family?

Yes No
Please provide more details:
Membership

180
Membership Fee:

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

Should be Empty:

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