PICO - Areivim Program Registration Form

Areivim Program Registration Form
Registrant Information
Husband

First NameLast Name
Husband's Cell
Please enter a valid phone number.
Husband's Email
example@example.com
Husband's Date of Birth

MonthDayYear
Date
Wife

First NameLast Name
Wife's Cell
Please enter a valid phone number.
Wife's Email
example@example.com
Wife's Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Address

Street Address

Apt/Unit

CityState / Province

Postal / Zip Code
Number of Unmarried Children less than 32 years old:
Kehilla
Medical History
A medical history may or may not affect your eligibility for Avreichim USA membership.

Wife*

	Yes	No
Stroke/High Blood Pressure/Neurological Disorder
Heart/Lung/Kidney/IBD Disease
Diabetes
Cancer
Substance Use

Husband*

	Yes	No
Stroke/High Blood Pressure/Neurological Disorder
Heart/Lung/Kidney/IBD Disease
Diabetes
Cancer
Substance Use

Areivim Program Registration Form