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Chabad of the Five Towns

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Upcoming Events

Six Flags Trip

Number of Teens Resgistering*
Teen #1 Information
Full Name
First NameLast Name
Grade
School
Teen Cell Number
Area CodePhone Number
Teen #2 Information
Full Name
First NameLast Name
Grade
School
Cell Number
Area CodePhone Number
Parent Information
Mothers Name
First NameLast Name
Mother Cell Number
Area CodePhone Number
Fathers Name
First NameLast Name
Father Cell Number
Area CodePhone Number
E-mail to receive confirmation*
To make alternate payment plans please contact Hadassah: 516-458-3694
Number of Teens Registering$55 Per Student

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Total
$0.00
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