Rosh Chodesh Society II

PLEASE INDICATE IN THE NOTES SECTION IF YOU ARE ATTENDING THE MORNING (10:30AM) OR EVENING (7PM) CLASS)

Personal Information

First Name *

Last Name *

Please be sure to write your FULL street address and apartment number if applicable

Street Address *

City (Primary) *

State (Primary)

Email *

Phone *

Notes

Program Fee *

JWC Member Price - $ 120.00

Non JWC Member Price - $ 150.00

Single Class (Book not included) - $ 30.00

I am already a member - $ 0.00

Total

Authorize.net (Credit Card)

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *