Print the form, complete, sign and bring or Fax: (330) 867-8498 to Jewish Heritage Video Collection at the Educational Resource Center, 750 White Pond Drive, Akron, Ohio 44320. Please PRINT or Type.

Name  

Address  

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Day Phone     Night Phone  

Additional Member  
Age  

Additional Member  
Age  

I agree to the terms of the JHVC as listed in the Rental Agreement.

Signature____________________________  

Date ____________________