This form can be used to make a payments/register to the Chabad House for: Trips, Events, Books, Tuition/Tutoring, Judaica Items, Etc.

First Name

Last name

Address
City
State

Zip Code


Phone


E-mail

Please check off the events/programs you would like to register or make a payment for:

Bar/Bat Mitzvah Club

$150
$115 Chai-Club Members
     
Chanukah Dinner
$18 adult
$10 child 
$100 Sponsor
 
     
Other  

Name(s) of Participants

Comments:

Payment Info:

Amount to charge
Invoice # (if applicable)


Credit Card #
Expiration
CVV