Beth Shalom Congregation

Please complete all information. Fields marked with an asterick (*) are required. E-mails received after the cut-off date, October 2ndmust pay the higher charges. Absolute last date for reservations is October 15th.

Full Name*
Address*
City*
State*
ZIP*
E-Mail*
Phone*
Today's Date:
# Adults
Prior to Cut-Off Date	@ $18.00 per person =	$
After Cut-Off Date	@ $24.00 per person =	$
# Children 5-17
Prior to Cut-Off Date	@ $12.00 per person =	$
After Cut-Off Date	@ $18.00 per person =	$
# Children <5	Free
Family Special
Prior to Cut-Off Date	@ $45.00 per Family (2 adults & up to 2 children)	$
Prior to Cut-Off Date	@ $9.00 for each additional child	$
After Cut-Off Date	@ $50.00 per Family (2 adults & up to 2 children)	$
After Cut-Off Date	@ $9.00 for each additional child	$
Total Payment	$
I will pay:	Send Check to: Congregation Beth Shalom 5915 Beacon Avenue Pittsburgh, PA 15217