Shavuot Family Mitzvah Day Registration

FAMILY MITZVAH DAY REGISTRATION
Full Name*
First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number
Adults Attending*
Children Attending*
PATIENT VISITING
I would like to volunteer and help distribute Shavuot gift bags to patients*

YesNo
With whom are you volunteering?

My familyAs a friend groupOn my own
How many adults?
How many children?
With how many people?
List the names of your friends:
I WOULD LIKE TO SUPPORT THIS PROGRAM
Amount

$50 CAD$75 CAD$100 CAD$180 CAD

Payment

Credit Card

We accept Visa, MasterCard, American Express
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

I hereby grant permission for photographs or videos of myself or my child to be used for promotional materials, including flyers, websites, and social media platforms.*

YesNo
Comments? Questions?
I would like to receive news and updates from ChabadHeart by email. I understand that information I provide to ChabadHeart will be used according to its Privacy Policy and I can unsubscribe at any time.
Should be Empty:

This page uses TLS encryption to keep your data secure.