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Kehillah New Year's Eve Eve Dance 2022
Contact Information
Participant's Name
*
First Name
Last Name
Participant's Date of Birth
*
(mm/dd/yyyy)
Participant's Grade Level (if applicable)
Participant's Phone Number
*
Participant's Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Please list any of the participant's food allergies in the box below (if applicable)
Parent/Guardian's Name
*
First Name
Last Name
Second Parent/Guardian's Name
First Name
Last Name
Parent/Guardian's Address (if different from participant's)
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Parent/Gaurdian's Primary Phone Number
*
Parent/Gaurdian's Secondary Phone Number (if applicable)
Parent/Guardian's Email
*
Verify Email
*
Emergency Contact's Name
*
First Name
Last Name
Emergency Contact's Phone Number
*
Emergency Contact's Relationship to Participant
*
Tickets
The whole family is invited to stay and celebrate with us! How many people in your family will be attending the dance? Please list name and select member or non-member
Number of JCC members attending
Quantity
$15
0
1
2
3
4
5
6
7
8
8
Number of general public attending
Quantity
$20
0
1
2
3
4
5
6
7
8
8
Please list all the names of those who will be attending in the box below
*