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Rekindle Shabbat Registration                                         





Family's last name First name
First name of partner   Last name of partner (if different)  
Names and DOB of your children
Child one     D.O. B. 00/00/0000 month day year
Child two     D.O. B. 00/00/0000 month day year
Child three   D.O. B. 00/00/0000 month day year
Child four     D.O. B. 00/00/0000 month day year
Address     Apt. #  
City             State        Zip
Home phone Email
I keep a kosher home yes no

Mother's religion

Father's religion

I was referred by: Name of synagogue (if affiliated)
Are you new to Rekindle Shabbat? yes no I am attending the educational workshop
(mandatory for new families) at:
Woodbridge Assisted Living
240 Lynnfield Street
Peabody
Monday, October 25, 2010 at 7:30 p.m                  yes no
Please choose how you would like to partcipate:

I have a buddy family. My buddy family's name and contact information is:

Match me with a buddy family .  
I want to particiapate with just my family.