CHAI Online Registration - Dix Hills Jewish Center

"*" indicates required fields

Registrant #1 Name*

First Last

Registrant #1 Email*

Registrant #1 Phone*

Registrant #1 Course Selection*

Registrant #2 Name

First Last

Registrant #2 Email

Registrant #2 Phone

Registrant #2 Course Selection

Address*

Street Address Address Line 2 City State ZIP Code

Synagogue Affiliation

Not a prerequisite for CHAI registration

Product Name

$48 for the entire household for the six week semester of courses and lectures.

Total (including 3.5% online processing fee)

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

If you are paying on line, please email gjospa@optonline.net with your Name, email address, and class choices, so that we will be able to email you the weekly links for your classes.