Printed from ShalomChabad.com

Reserve Your Spot Today!

Reserve Your Spot Today!

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Chabad of Bethesda Community Israel Trip
Registration Form

April 28-May 8, 2017

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Dear Participant:

Please fill in this form in its entirety so that we may have a full record of your registration. Please fill out a separate form for each person that will participate. If you have any questions or comments, please feel free to contact us at the Chabad of Bethesda at  info @shalomchabad.com or 240-370-8819. Thank you and looking forward to traveling with you!

PARTICIPATNT INFORMATION

 

Last Name First Name 

Hebrew Name

 

 

 

Cell Phone  Email

 

 

 DOB / /   Age

Passport Number   Passport expiration Date  
  (passport must be valid for at least 6 months after date of trip.

 

INFORMATION

 
Street Address     

 


 

Home Phone
 

HEBREW EDUCATION INFORMATION

Level of Hebrew Reading Proficiency:
None Basic Intermediate Advanced
 
MEDICAL INFORMATION (optional)

 

Family Physician

Phone

Insurance Policy #

 

  Up to date w/ vaccinations? Yes No Date of last tetanus:

Any special medical conditions?

 

Emergency Contact

Phone

Relation to Participant        

 

DEPOSIT INFORMATION (Due Today)

 

Per Participant: $500.00

Payment of Trip Balance will be due by March 15, 2017
Full payment amount TBD

 

Checks are Chabad of Bethesda's preferred mode of payment, please make checks payable to 'Chabad of B-CC' all checks must be mailed to Chabad of B-CC, 5713 Bradley Blvd, Bethesda, MD 20814.

 

AGREEMENT

 

As the participant in the above trip, I authorize any adult acting on behalf of Chabad of Bethesda to hospitalize or secure treatment for me, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad of Bethesda personnel will try to communicate with me prior to such treatment. I hereby give my permission to participate in all trip activities and allow myself to be photographed while participating in the trip and activities and that these pictures may be used for marketing purposes. If payment is made by credit card, I give Chabad authorization to charge an additional 2.5% processing fee on my card.

I Agree

 

Digital Signature (please type full name) Initials Date

 

 

PAYMENT INFO

DEPOSIT OF $500

NOW ONLINE - FILL OUT FORM BELOW

LATER - AMOUNT OF INTENDED PAYMENT

 Online Payment Form

Check box if billing contact info is same as above (then move on to 'Amount')

First name          Family name

 

Billing Address Apt #

 

City State Zip

Phone # Email


Amount: $

Card Type

Card#

Exp Date: /CVV Code (3 digits on back)

 

Comments:

All payments made by credit card will be subject to 3% processing fee

Thank you for making a deposit for our upcoming Israel Experience!
If you need to contact us directly, please call 301 913-9777

 



 

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