... and/or your family members are not included in these materials. Jewish Community Center of Northern Virginia. 8900 L
Program Registration Form
[email protected] Please complete the form below and enclose a check made payable to the JCCNV, or provide your Visa, MasterCard or American Express number, expiration date, security code and signature. All registrations must be submitted with payment. PLEASE PRINT AND FILL OUT COMPLETELY.
Date
o Male o Female
Participant’s Name Middle Last Parent/Guardian’s name if participant is a minor Address Apt. City State Zip Phone (H) (Work/Cell) E-mail D.O.B. If Child, Age Grade Is child enrolled in JCCNV day care on the day of this class? o Yes o No Names of other participants attending program o Male o Female o Male o Female o Male o Female o Male o Female Emergency Contact Name Phone
Relationship
CODE ACTIVITY COST $
$
$
$ I want to help support important programs at the JCCNV by making a donation to one or more of the following funds (suggested gift: $18). Feel free to provide an alternative amount below for your 100% tax-deductible gift. $ $
Family Programming
$
Adult Programming
$
$
Cultural Arts
$
Community Engagement $
$
Other
Donation Total
General Operations
Health, Fitness & Aquatics Fund Special Needs
Program and Donation Total
Member #
No credit cards accepted for Adult Trips
Total Enclosed $
o Check #
o VISA o MasterCard o American Express o Cash
Cardholder’s Name (please print) Card Number Expiration Date
Security Code
Signature
Please consult your physician before beginning any physical activity or engaging in any physical program. The JCCNV reserves the right to photograph and/or videotape activities for use in publicity and promotional materials. Please notify the JCCNV in writing if you do not want photos of either you or your family members to be used and send in a recent photo so that we can be sure that you and/or your family members are not included in these materials. Jewish Community Center of Northern Virginia 8900 Little River Turnpike • Fairfax, VA 22031 jccnv.org • 703.323.0880 • Fax 703.323.1993
