Printed from ChabadWesthempstead.org

Mitzvah Kids Registration Form

Mitzvah Kids Registration Form

 
ABOUT SCHEDULE PHOTOS REGISTER
 
Click here to download and print the registration form
First Name
Last Name
Age
School
Address
City/Zip
Phone Number
Parents Email Address
Mother Cell Number Father Cell Number
Emergency Contact #
Allergies (if any)
Hebrew Name
Birthday
Comments

The cost to enroll is $100.00 for the Mitzvah Kids program

Please choose one of the following payment plans

Payment in full $100

2 installments of $50 (with head checks)

I will pay by Check Credit Card

Name on card Credit card type
Card number Security code
Expiration month Expiration year
Total amount to be charged
Comments
 
Please check if you would like to sponsor another child for this club
 
A project of Chabad of West Hempstead
565 Nassau Blvd • West Hempstead, NY 11552 • 516-483-1683
Email:
chayarochel@yahoo.com

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