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Youth Hebrew School

PS 234 Pickup Registration

PS 234 Pickup Registration
Parent's Name*
First Name Last Name
E-mail*
Number of Children being dropped off* $750 per child
Child 1 Name*
First Name Last Name
Child 1 Grade* eg: "First Grade"
Child 2 Name*
First Name Last Name
Child 2 Grade* eg: "First Grade"
Child 3 Name*
First Name Last Name
Child 3 Grade* eg: "First Grade"
Child 4 Name*
First Name Last Name
Child 4 Grade* eg: "First Grade"
Total

$0.00

Payment

Credit Card

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

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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