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Youth C-TEEN JR.

Register Your Daughter- Chai5

Chai Five For Girls Registration Form
YES! I want to register for Chai Five Girls Club!!
My Name*
My Hebrew Name*
My Birth Date*

Month Day Year
My Hebrew Birthday*
My School*
My Grade*
Gender*

My Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

My Phone Number*

- Area Code Phone Number
Father's Name*
Father's Phone Number*

- Area Code Phone Number
Mother's Name*
Mother's Phone Number*

- Area Code Phone Number
E-mail*
Payment

(fee must be paid in full before the start of the club)

Payment*

Credit Card Other

Postal / Zip Code

Country

Amount*

$150
*Please click the submit button only once. Thank you!
Should be Empty:

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