Children's Program

Please scroll down to register
Message for members of 5784 (2023-2024): If you are a member, please contact the office to make your children's program reservations 386-672-9300. Thank you
General Information
Parent's Full Name*

Last Name First Name
E-mail*
Phone Number*

Area Code Phone Number

Address*

Child & Program Information
How many children are you registering for?*
Child #1 Name*

Last First
Child #1 Grade*
Child #1 Programs Selected*

Individual Program (10$ per child)High Holidays + Shavuot ($40 per child)Full year Shabbos ($250 per child)
Child #2 Name*

Last First
Child #2 Grade*
Child #2 Programs Selected*

Individual Program (10$ per child)High Holidays + Shavuot ($40 per child)Full year Shabbos ($250 per child)
Child #3 Name*

Last First
Child #3 Grade*
Child #3 Programs Selected*

Individual Program (10$ per child)High Holidays + Shavuot ($40 per child)Full year Shabbos ($250 per child)
Child #4 Name*

Last First
Child #4 Grade*
Child #4 Programs Selected*

Individual Program (10$ per child)High Holidays + Shavuot ($40 per child)Full year Shabbos ($250 per child)
Child #5 Name*

Last First
Child #5 Grade*
Child #5 Programs Selected*

Individual Program (10$ per child)High Holidays + Shavuot ($40 per child)Full year Shabbos ($250 per child)
Please select Program date*

Month Day Year
Payment Information
Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
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

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