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OF ROSLYN & OLD WESBURY

Holocaust Fellowship Registration

Holocaust Fellowship Registration

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
State NY Zip
Home Phone Cell Phone
Email
Allergies Synagogue Affiliation
 
 
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 Yaakov Wilansky of CTeen of Roslyn from March 30, to April 3, 2016.
Parent Guardian Name Participant Name
Date
       

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 Scholarship price *$350.00  Full price $500   Donate *$0.00 Total *$350.00
I would like to help sponsor a teen who lacks the funds to participate

Payment Method    
Name on Card Card Number
Exp. Date CVC Number
Address City
State Zip
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
 
FEEDBACK
How did you hear about this retreat?
Comments/Questions/Blessings

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