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Please enter information on this form to make payment for
JEC HS Shabbaton.
First Name
*
Last Name
*
Phone
*
Email
*
Grade
*
--Select--
9
10
11
12
Parent Cell
*
Student Cell
*
Where would you like your son to return on Saturday night?
*
--Select--
Elizabeth/Hillside
Edison/Highland Park
Staten Island
Passaic - Yeshiva Ketana
West Orange
Brooklyn
Monsey - Wesley Kosher
No transportation needed
Home Address
*
By checking the box I agree that my child, whose name is stated above in box one, has permission to attend the JEC High School Shabbaton, September 16-17 2022. I understand that my son is to follow all rules as set forth by the trip chaperones.
*
I agree
I do not agree
If needed - a JEC staff member may give my son medication
*
I agree
I do not agree
Please type your name in the box to confirm your consent and identity.
*
Comment
Coupon
The coupon code you entered is invalid or expired
Total Amount
$
Discount Amount
$
Gross Amount
$
Payment method
*
Paypal
Credit Card
Billing Zipcode
*
Credit Card Number
*
Expiration Date
*
01
02
03
04
05
06
07
08
09
10
11
12
/
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Card (CVV) Code
*
Card Type
*
Visa
MasterCard
Discover
American Express
Card Holder Name
*
Verification code
*
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