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Youth Programs Ckids Club

CKids Club Register

Please fill out a separate form for each child.
Child's Name*

First Name Last Name
Birthday*

Month Day Year
*

Yearly Membership ($100) Single Session ($20)
Parent's Name*

First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number

Payment

Credit Card

Credit Card Type
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

Please email checks to:
Chabad of Homestead 8460 SW 198th St
Cutler Bay, Fl 33189
I would like to receive news and updates by email
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Programs