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Registration

Registration

B"H 

MotherDaughter_2014_Final.jpg

Be part of this exclusive club! For girls in grades 5-7 

 

8 Thursdays, 6:30-8:00

 

Membership fee: $150

 

For more info email Mushka@Jewishnortheast.com  

 

 

 Name:                         

 Hebrew name:      

 Date of birth:                    

 

Guardians Name:     

Phone number:       

Email:                         

Address:                  

Zip code:                

 

Emegency contact:

Name:                       

Relationship:            

Phone number:        

 

 

Comments: (Please make note of any allergies or special concerns)
 

 

 

 

 

Payment: 

 

 

Name on Card: 

 

 

CC number:         

 

 

Expiration date:  

 

 

CVV                     


 

Billing address:  

 

 

Billing Zip:                

 

 

I will mail a check to 2125 Ne 45th, Portland 97213

  

 

 

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