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
     
Purim Party
$15 adult
$10 child
$50 Family Max 
$180 Sponsor

After March 14th add
$5 per person
$20+ per family Max 

     
Other  

Name(s) of Participants

Comments:

Payment Info:

Amount to charge
Invoice # (if applicable)


Credit Card #
Expiration
CVV