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Valley Chabad Teen Leadership Initiative Registration Form
Student's Full Name

First Name Last Name
Hebrew Name
Birth Date

Month Day Year
School Attending:
Grade
Hebrew School Attended
Programs looking to get involved in. Check all that apply.

CTeen Friendship Circle Linking Hearts JLI Teens Eternal Flame
Address
City/State/Zip
Teen's Cell Number

Area Code Phone Number
Parents' information
Marital Status

Married Divoriced Seperated Widowed
Mother's Name

First Name Last Name
Mother's E-mail
Mother's Cell Number

Area Code Phone Number
Father's Name

First Name Last Name
Father's E-mail
Father's Cell Number

Area Code Phone Number
Notes:
We will reach out to you once the form is submitted. For questions or for more information email [email protected] or call our office at 201.476.0157.
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Valley Chabad Teen Leadership Initiative offers a wide range of educational, social, and community service opportunities for local Jewish Teens. Sponsored in part by a grant from the Slomo and Cindy Silvian Foundation

Valley Chabad Teen Leadership Initiative Registration Form