Bnei Akiva EventsName* First Last Phone*Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Choose your event*Choose your eventHashachar - Kickoff Pizza PartyShirt Size*SMPlease indicate any dietary restrictions or allergies you may have.OHIP Number:*Please indicate any medical information you feel is important for us to know: Emergency Contact Info Name* First Last Phone*Will you be needing a walking group?* Yes NoI have filled out the safety waiver* Yes NoQuantityTotal $ 0.00 CAD This sum is to be donated in order to complete your sign up. Follow the instructions given on the next page, after submitting this form. How would you like to pay?* Credit Card CashCredit Card*MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Coupon
