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Mommy & Me Registration

Mommy & Me Registration

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I would like to register for the Mommy & Me Program at the Chabad of Uptown

Child's First Name:  Last Name: Hebrew Name:  

D.O.B.              Male  Female

Mother's First Name:  Father's First Name:  Last Name:

Address:
     City, ST Zip:

Phone:
 e-mail:  Cell:

Does your child have any allergies? Yes No

If yes, what are they?

Is there another day of the week that would be more convenient for you? 

 

 I woud like to be a sponsor for only $180.

Comments: 

I heard about the Uptown Mommy & Me from:

 I will pay $7 per child in person by check or cash.

PREFERRED: Please charge my credit card, and let me get this out of the way:

 
 
Name on card:
Card No.

Exp:mm/yyyy /
CVV Security Code:
What's This? 

Send me confimation via email

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