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Boy's Name:

Boy's Hebrew Name (If known):

Birth Date: Time of day born:

Current Grade:

Address:

Home Telephone Number:

Boy's Cell Number:           

Boy's E-mail: 

Father's Name:

Father's Cell Number:

Father's E-mail:

Mother's Name:

Mother's Cell Number:

Mother's E-mail:

 

MEDICAL EMERGENCY INFORMATION:

In case of emergency, when neither parent can be reached, please provide an emergency contact: 

   Name:      Emergency Contact Number: 

Allergies:  


Cost:  $ 200

 Please charge my credit card the full amount

 Please charge my credit card $25 a month for 8 months



PAYMENT INFORMATION:

Credit Card

Name:

Street address:

City, State, Zip:

Phone Number:

Amount to charge:

Name on Card:

Credit card number:

Expiration Date:

Mailing check to: Chabad of West Boca Raton  19701 State Road 7  Boca Raton  33498