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Youth CKids Club JewQ

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Childs Information
Full Name*

First Name Middle Name Last Name
Hebrew Name*
Birth Date*

Month Day Year
Grade*
E-mail* Parents

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number* Parents

Area Code Phone Number
Registration fee* Book included

$36.00

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

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