Tzivos Hashem Registration

Tzivos Hashem 5781 - 2021
Fill in this form to pay for Tzivos Hashem registration in 12 monthly instalments of $6 per month.
Child 1
Child 1 Full Name*
First NameLast Name
Child 1 Hebrew Name*
Child 1 English Birthday*
DayMonthYear
Child 1 Jewish Birthday*
Child 1 School*
Child 1 Year Level 2021*
Child 1 Teacher*
Child 2
Child 2 Full Name
First NameLast Name
Child 2 Hebrew Name
Child 2 English Birthday
DayMonthYear
Child 2 Jewish Birthday
Child 2 School
Child 2 Year Level 2021
Child 2 Teacher
Child 3
Child 3 Full Name
First NameLast Name
Child 3 Hebrew Name
Child 3 English Birthday
DayMonthYear
Child 3 Jewish Birthday
Child 3 School
Child 3 Year Level 2021
Child 3 Teacher
Child 4
Child 4 Full Name
First NameLast Name
Child 4 Hebrew Name
Child 4 English Birthday
DayMonthYear
Child 4 Jewish Birthday
Child 4 School
Child 4 Year Level 2021
Child 4 Teacher
Child 5
Child 5 Full Name
First NameLast Name
Child 5 Hebrew Name
Child 5 English Birthday
DayMonthYear
Child 5 Jewish Birthday
Child 5 School
Child 5 Year Level 2021
Child 5 Teacher
Payment Details
Parent Name*
First NameLast Name
Parent E-mail*
Parent Phone Number*
Total number of children registering for Tzivos Hashem 5781 - 2021*
Name on Card*
Credit Card Number*
Expiry Date*
I confirm that my payment details are correct.
By clicking submit, I agree to be charged $6 per child per month for the next 12 months.
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Tzivos Hashem 5781 - 2021