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At Chabad at the Beaches

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Fire & Ice Festival

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Registration Info
Full Name*

First Name Last Name
E-mail*
Phone Number*

Area Code Phone Number

Address*

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

Number of Adults*
Number of Children
This event is FREE of charge - donations/sponsorships welcome!
I/we would like to make the following contribution.

$18 $36 $72 $180
Total

$0.00

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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