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Register

Register

BH

Yachdav Registration Form

2017-2018

 

(This form is secure)

Last Name*: new.jpg

First Name*:

Hebrew Name*:

DOB/Age*:

Gender*:

Home Address*:

City - State - Zip*:

Tel*:

Email*:

Entering Grade Sep. 2016*:

Parents Name:

**************

Payment Options:

I will mail a $600 Check payable to Chabad of the Central Cascades.

Charge my Credit Card $615 ($15 surcharge for paying by credit card)

Credit Card Type:

Name on Card:

CC # :

Exp. Date:

CVV2 (last three digits on back of card):

Billing Address (if different):

 

Commends and Special Requests:

 

 

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