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OF VALENCIA

CTeen Registration

Teen's Info
Full Name*
First NameLast Name
Phone Number*
- Area CodePhone Number
E-mail
Birth Date*
MonthDayYear
School*
Grade*
2016-17
Best way to keep in touch with teen
Add to mailing list
Parent's Information
Mother's Name
First NameLast Name
Mother's Cell
- Area CodePhone Number
Mother's E-mail
Father's Name
First NameLast Name
Father's Cell
- Area CodePhone Number
Father's E-mail

Address

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

Home Phone
- Area CodePhone Number
Payment
The annual cost of CTeen membership is $180 for the school year. We will meet twice a month. One will be a class/discussion and the other a social gathering. CTeen Members also receive discounts on trips, national and international gatherings, and Cteen summer experience.
I wish to pay with*
1 Payment of $1802 Payments of $904 Monthly Payments of $45
Optional: I would like to sponsor a teen in the amount of
$50$100$180

Payment

Credit Card

Credit Card Type
- Credit Card Number	Security Code
Name on Card

/ Expiration MonthExpiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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