Club 345 Goes Roller Skating! – Temple Israel of Hollywood

Child Name(Required)

First Last

Child Date of Birth(Required)

Child Grade(Required)

3rd Grade

4th Grade

5th Grade

Allergies/Dietary Restrictions

Parent Name(Required)

First Last

Parent Phone Number(Required)

Parent Email Address(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

Meals and Additional Purchases(Required)

I acknowledge that my child will be provided pizza at TIOH before leaving for the event. Any additional snacks or purchases are my responsibility.

Registration(Required)

Amount:

Coupon

CC Fees

I wish to cover credit card fees for the temple by increasing my total by 3%

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

PLEASE NOTE: A waiver will be sent to the email address you listed above. Registration will NOT be complete until this waiver has been submitted.(Required)

I acknowledge that registration is not complete until this waiver has been submitted.