I wish to reserve at the Purim Event:

 

Adults......$36.00

 

Children 12 and under....$15.00

 

 

I would like to be a
Hippie Sponsor $180

 

I would like to be a
Peace Sponsor $360 


Please type the name(s) of those who

will be attending:

 

Credit Card Information:

 

Total to charge:

 

Card Type:

Card Number:
  (Please enter only digits)
Valid Until:

PLEASE NOTE: The name below must match the information on credit card .
First Name:
Middle Name:
Last Name:
Street Address:
 
 
City:
State:
Zip Code:
   
Email:
Please Retype
Email:
Phone: