Pizza Form

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Cheder Menachem Pizza Order Form

Hot & Delicious Pizza Lunches Every WEDNESDAY

From Pizza Station

Please note: MONTHLY ORDERS ONLY!
Parent Name*
First Name Last Name
E-mail*
No. of Children*
Child 1 Name*
First Name Last Name
Child 1 Grade*
Child 1 Monthly Option 1 Slice ($3.50)

May: 6, 13, 20, 27June: 3, 10
Child 1 Monthly Option 2 Slice ($6.00)

May: 6, 13, 20, 27June: 3, 10
Child 2 Name
First Name Last Name
Child 2 Grade
Child 2 Monthly Option 1 Slice ($3.50)

May: 6, 13, 20, 27June: 3, 10
Child 2 Monthly Option 2 Slice ($6.00)

May: 6, 13, 20, 27June: 3, 10
Child 3 Name
First Name Last Name
Child 3 Grade
Child 3 Monthly Option 1 Slice ($3.50)

May: 6, 13, 20, 27June: 3, 10
Child 3 Monthly Option 2 Slice ($6.00)

May: 6, 13, 20, 27June: 3, 10
Child 4 Name
First Name Last Name
Child 4 Grade
Child 4 Monthly Option 1 Slice ($3.50)

May: 6, 13, 20, 27June: 3, 10
Child 4 Monthly Option 2 Slice ($6.00)

May: 6, 13, 20, 27June: 3, 10
Sponsor another child ($112 each)

One Child's PizzaTwo Chilren's PizzaThree Children's Pizza
Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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