Chabad of Bethesda Community Israel Trip
April 28-May 8, 2017
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!
Last Name First Name
Cell Phone Email
DOB / / Age
Passport Number Passport expiration Date
(passport must be valid for at least 6 months after date of trip.
Insurance Policy #
Up to date w/ vaccinations? Yes No Date of last tetanus:
Relation to Participant
Per Participant: $500.00
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.
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.
Digital Signature (please type full name) Initials Date
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
CVV Code (3 digits on back)
All payments made by credit card will be subject to 2.5% 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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