Pre-Chanukah @ Palisades Village more...

Printed fromChabadPalisades.com

ב"ה

PJECC Unplugged

1. Family Information
Name of Adult 1*

First Name Middle Name Last Name
Name of Adult 2

First Name Middle Name Last Name
Home Phone*

Area Code Phone Number
Cell Phone*

Area Code Phone Number
E-mail*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

My family will be attending the Shabbaton* $750 per family

Yes Regretfully Not
Number of adults attending*
Number of children ages 5 and under* Free
Number of children ages and above* $150 per child ages 6 and above
2. Children's Information
Name of Child #1*

First Name Last Name
Child #1 Birthdate*

Month Day Year
Child #1 Age*
Name of Child #2

First Name Last Name
Child #2 Birthdate

Month Day Year
Child #2 Age
Name of Child #3

First Name Last Name
Child #3 Birthdate

Month Day Year
Child #3 Age
Children under 5 accomodations (if applicable)
Please list any dietary restrictions in your family
Does your family have any special medical needs?
Are you celebrating any birthdays or anniversaries this weekend?
Payment
Total

$0.00

Payment*

Credit Card Check, Cash, Pay at office

Postal / Zip Code

Country

General comments
Should be Empty:

This page uses TLS encryption to keep your data secure.

Programs