Purim at the Shore Registration

Purim at the Shore Reservations

First Name:   

Last Name:   

Address:

City:      

State:   

Zip:      

Phone #:

Email  

Number of people attending:

#  of Adults and children 14 and older    $28 per Person

 # of Children:  3-13 years $10

Children under 3 free 

I want to make a contribution to help sponsor the Purim Fest! ( your Name will be announced at the event) of:

$3600.00	$1800.00	$1000.00	$500.00
$180.00	$100.00	Other $ US

Payment information

 I will pay with a credit card     check/cash

 Signature of name on card

Total  $  

*Please mail check to the

Chabad Center 194 Ratzer Road Wayne NJ 07470

in time for it to arrive at least 3 days before the event.