Event Reservation Form

Contact Information

Your Title

*

Your First Name

*

Your Last Name

*

Address

*

City

*

State

*

Zip

*

Email

*

Child Information

Selection	Number of Children	Amount	Total
Chai Kids - Single Class ($15 at the door)		12.00
Single Class ($15 at the door)		12.00
Total

	#	Selection	Child's Full Name *	Child's Birthday *

Reservation Amount

*

Payment Information

Card Number

*

Card Expiration

*

*

Security Code

*

Same as contact info

Billing Address

*

Zip Code

*

Name on Card

*

secure

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