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PURIM DINNER REGISTRATION FORM
Thursday, March 21, 2019 • 6:00pm

 

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

Adults: $27 ($32 after March 14)
Children: $16 (ages 3-12) ($19 after March 14)

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:

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