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PURIM REGISTRATION FORM
Tuesday March 10, 2020 • 6:00pm

                                                                            First Name:
                                                                            Last Name:
                                                                            Address:    
                                                                            City:           
                                                                            State:          Zip:
                                                                            Phone:       
                                                                            Email:         

Adults: $27 ($32 after March 3)
Children: $16 (ages 3-12) ($19 after March 3)

How many adults?   
How many children?

––––––––––––––––––– Sponsorship –––––––––––––––––––

Check this box to be a sponsor ($180) 

––––––––––––– Payment Information –––––––––––––
To pay by credit card, please complete the following:


Card type:

Name on card:
          Card no:
              Expiration date:     CVV:            

Enter total amount:
________________________________
To pay by check, please complete:

I will mail a check:
Enter Total Amount:
to Chabad of the Inland Empire
8710 Baker Avenue, Rancho Cucamonga, CA 91730
(909) 949-4553