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Washington Application Form

Washington Application Form

STEP 1: REGISTRATION FORM

Registration 2016 is now open! (Please take a moment to read the trip info page it will answer most of your questions regarding this event.)


PARTCIPANT INFO
First Name Last Name
Gender Male Female School Attending
Address City
Province Postal
Home Phone Cell Phone
Email
Allergies Synagogue Affiliation

Reference is a Rabbi or Teacher who knows the participant and can be called as his / her reference.
Reference Reference Position
Reference Phone
PARENT INFO
Mom First Name Mom Last name
Mom Cell Number Mom Email

Dad First Name Dad Last name
Dad Cell Number Dad Email
PERMISSION TO TRAVEL
Please let it be known that I, the undersigned, give permission for my child to travel to Washington DC, USA with Rabbi Shmuli Nachlas of Jewish Youth Network from March 31, to April 3, 2016.
Parent Guardian Name Participant Name
Date
Province City
ROOMING REQUESTS
Rates are based on Rooms which hold 4 guests. You may make up to three rooming requests, of whom you would like to room with. Late applications lessen the chance of us being able to honour your request. We will try our hardest to honour at least one of your requests.
Request 1 Email
Request 2 Email
Request 3 Email
BILLING INFO
Cost *$495.00 Donate *$0.00 Total *$495.00
I would like to help sponsor a teen who lacks the funds to participate

Payment Method Amount $
Name on Card Card Number
Exp. Date CVC Number
Address City
Providence Postal
Due to credit card company fees, we will be processed credit card with an additional 3% surcharge.
Please email confirmation to the following email address
*Being that group rates must be booked well in advance, registration after March 6. will be $575.00
FEEDBACK
How did you hear about this retreat?
Comments/Questions/Blessings