Madlik: Illuminating the World

REGISTRANT INFORMATION

Registrant Name*

Prefix First Last Suffix

Email*

Home Phone*

Mobile Phone Number (If different)

Registrant Address*

Street Address City State ZIP Code

ESER Site First Choice*

Second Choice

Third Choice

Photo Waiver*

I understand that my picture may be taken during the course of this program, and I agree to its use on the website or in other promotional materials.

Billing Address

Same as Registrant Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number (as it appears on credit card statement)*

Total

$0.00

Credit Card

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Are you open to hosting your Eser group in your home?*

How did you hear about Eser? (indicate all that apply):

Other: (Please describe)

What motivated you to sign up for Eser?:

Other: (Please describe)

Anything else we should know?

Age*

Eser is designed for young adults in their 20s and 30s. Please visit Adult Learning at Hebrew College for opportunities for all ages

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