PAS Beren Deep Dive Tuesday, November 4

Adult Information

First Name

Last Name

Phone

Total number of adults attending the event:

Second Adult Information

First Name

Last Name

Phone

How many students are you registering?

Student

First Name

Last Name

Phone

Grade

Name of School

Second Student

First Name

Last Name

Phone

Grade

Name of School

Third Student

First Name

Last Name

Phone

Grade

Name of School

Fourth Student

First Name

Last Name

Phone

Grade

Name of School

Our family is part of (check all that apply):

Park Avenue SynagogueUJA's PACT ProgramAnother synagogue / organization

Please share the name of the synagogue or organization:

A kosher dinner will be served. Please let us know if anyone in your party has any dietary restrictions:

Do you have a discount code?

Please enter the code below

Prediscount Total

Discount Amount

Total ($18/per person)

Credit Card Information

First Name on Card

Last Name on Card

Credit Card Number

Exp Month

Exp Year

Security Code

Billing Address

Billing City

Billing State

Billing Zip Code

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