Kids 'n Action - Sign Up $125 - annual membership Father's First Name Mother's First Name Address City Postal Code Phone Email Address Child's First Name Child's Last Name School Grade Birthday (mm/dd/yyyy) Emergency Contact Number I/We hereby authorize our child to participate in all Mini Chefs activities Please charge my card in the amount of: $125 / $ Other Form of payment: Card Number 01 02 03 04 05 06 07 08 09 10 11 12 Month 2013 2014 2015 2016 2017 2018 2019 Year I will mail my check payable to Chabad of the Tri-Valley to: 784 Palomino Drive - Pleasanton, CA 94566 Please provide any additional comments here: Questions? Please call (925) 846-0700 or email: [email protected] This page uses 128 bit SSL encryption to keep your data secure.