Register - Chabad of Bensonhurst

Registration Form 2024
If you would prefer to fill this out on paper, a fillable PDF can be found here.
CTeen Member's Info:
CTeen Member's Name*
First Name Last Name
Cteen Member's DOB

Month Day Year
CTeen Member's Email*
CTeen Member's Cell Phone*

Area Code Phone Number
CTeen Member's School
CTeen Member's Graduating Year*
Parent's Info
Parent's Full Name*
First Name Last Name
Parent's E-mail*
Parent's Phone Number*

Area Code Phone Number
Are Parents Jewish?*

Both JewishFather JewishMother Jewish
Sign Up!
I WOULD LOVE TO JOIN CTEENS! - REGISTRATION $99
Referral Program
Refer a friend! Friend's name and email address:
Save $25 off Registration When 1 Friend Signs Up!
Referral #1 Full Name
First Name Last Name
Referral #1 E-mail
Your refund will be issued as soon as one of your referrals signs up for the program!
After the first class, we cannot offer any refunds or credits (on any missed classes or events).
Payment
Scholarships Available.
No Jewish teen will be turned down!
Feel free to reach out to Mrs. Chana Hertz to work out the registration.
(347) 277-5040

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

City

State / Province

Postal / Zip Code

Country

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Registration Form 2024