Add Name Form - ChabadNoVa.org

Add a Name to the Refuah Shlaima List
Please complete the following fields; entries with and asterisk (*) are required to submit the name.
Please note: Submissions to be read on Shabbos must be posted before Thursday, 8:00 PM. If you have an addition after that time, please call the office. Local names are automatically removed after 30 days; requests from outside Northern Virginia are removed after 7 days. Please post the name again if needed. Also, please remember to remove names when they no longer need to be posted.

We regret that we cannot post listings if you do not provide a valid name and email address.
Your name:*
First Name Last Name
Your E-mail*
____________________________________________________________________________________________

For Jewish Persons, please complete this section. For Non-Jewish Persons, please complete the following section.
Patient's Hebrew/Jewish Name (if known):
Plese select one:

BenBas
Patient's Mother's Hebrew/Jewish Name (if known):
Patient's English Name:
If the patient is in a hospital, please provide the name of the hospital.
Please continue at the bottom of this form.
____________________________________________________________________________________________

For Non-Jewish Persons, please complete this section.
Patient's First and Last Name:
First Name Last Name
PLease select one:

Son ofDaughter of
Father's first name (if known):
Additional note (optional):
____________________________________________________________________________________________
Enter the message as it's shown*
I would like to receive news and updates by email
Should be Empty:

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Add a Name to the Refuah Shlaima List

For Jewish Persons, please complete this section. For Non-Jewish Persons, please complete the following section.

For Non-Jewish Persons, please complete this section.