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BAY: Teen Programming Registration

In order to create and run fun programming for our teens at CBI, we are asking for the information below and a registration fee of $50 per teen for the year. If the fee isn't doable for your family, just let Leah Bordman know at [email protected].

Please fill out a separate form for each teen! Thank you

* Student First AND Last Name:

* Student Date of Birth:

* Grade in school as of September 2023:

9th
10th
11th
12th

Student Phone Number:

Student Email Address:

* Select one or more options for student's preferred pronouns:

They, Them
He, Him
She, Her
Other (specify below)

Other preferred pronouns:

Please list any emergency medical conditions or information (allergies, medications, etc.)

* Guardian First AND Last Name:

* Guardian Phone Number:

* Guardian Email Address:

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

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