CTeen Long Island Shabbaton

Location: Long Beach, NY
Date: Friday, May 19 - Saturday May 20

Arrive at Host Family at 6:00pm on May 19
Shabbaton Ends Saturday Night
Full Name*

First Name Last Name
Phone Number*

Area Code Phone Number
E-mail
CTeen Chapter*
Have you ever been on a Shabbaton before?*

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Allergies?
Comments / Questions / Concerns
Grade
Cteen Rabbi name
Mothers name

First Name Last Name
Mothers number

Area Code Phone Number
Fathers name

First Name Last Name
Fathers number

Area Code Phone Number
Payment*

$99

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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