Sign up is as easy as... 1. Fill in the online application. 2. Go to the retreats calculation page to figure out cost. 3. Pay your sign up fee and partial or full retreat fees. Sign up for Bais Chana Summer Retreat Page 1 Contact Information First Name Middle Name Last Name Nickname (or first name again, if it's the same) Cell Phone Home Phone Preferred Phone NumberPlease select... Home Cell Email Address What's the best way for us to contact with you?Please select... Text cell phone Call cell phone Email Facebook Call home phone What's the second best way for us to contact you?Please select... Text cell phone Call cell phone Email Facebook Call home phone Hebrew name, if known Mother's Hebrew name, if known Date of Birth (mm/dd/yyyy) mm/dd/yyyy Marital StatusPlease select... Single Married Divorced Widowed Other Please explain. Permanent Address Street City U.S. StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY PR VI Northern Mariana Islands Guam American Samoa Palau Postal Code CountryPlease select... 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Share room, Name Share room, Phone Share room, Name Share room, phone Daily Rate Information Select the type of accommodations you preferPlease select... Double Room $200pp/night 3 meals, 6 classes Triple or Quad $160pp/night 3 meals, 6 classes Private $240/night 3 meals, 6 classes Arrival DatePlease select... Monday, July 23 Tuesday, July 24 Wednesday, July 25 Thursday, July 26 Friday, July 27 Saturday Night, July 28 Sunday, July 29 Monday, July 30 Tuesday, July 31 Wednesday, August 1 Thursday, August 2 Friday, August 3 Departure DatePlease select... Monday, July 23 Tuesday, July 24 Wednesday, July 25 Thursday, July 26 Friday, July 27 Saturday Night, July 28 Sunday, July 29 Monday, July 30 Tuesday, July 31 Wednesday, August 1 Tuesday, August 2 Wednesday, August 3 Will you need financial assistance or a payment plan to attend?YesNo If yes, please contact our office at 718.604.0088 or email firstname.lastname@example.org. Are you currently a student?Yes Will you need childcare during the retreat?Yes, I will need childcareNo, I will not need childcare Children Information Enter the first child's name, age and gender as demonstrated below John Doe - 6 - Male Add another child?Yes, please. Enter the Second child's name, age and gender as demonstrated below John Doe - 6 - Male Add a third child?Yes, please. Enter the third child's name, age and gender as demonstrated below John Doe - 6 - Male Page 3 Tell us about yourself What are you most looking forward to at the retreat? What topics are you most interested in hearing about? Have you ever attended a Jewish learning program? If so, please list when and what. What do you hope to gain by attending? Are you converting?Please select... Yes No Who is your conversion Rabbi? (Please provide a name and contact information.) Page 4 Important Information Do have any dietary needs or restrictions? Please be as specific as you can so we have what you need. If the answer is no, write no. Do you have any allergies, including penicillin? If the answer is no, write no. Significant medical history, if so, explain. If the answer is no, write no. Will you be taking any medications when you're with us? If so, please list. If the answer is no, write no. Emergency Contact Information Contact Name Phone Relationship to You Additional comments? Anything else you'd like us to know about you? How did you hear about this retreat? Please check all that apply.FriendFamilyFacebookOnline searchRabbi or RebbetzinOnline calendar listingSynagogue or Chabad HouseI'm a Bais Chana Alum!Other Family/Friend Who Introduced you to Bais Chana Referral First Name Referral Last Name Referral Phone Referral Email Add another referral name?Yes, please Ref 2 First Name Ref 2 Last Name Ref 2 Phone Ref 2 Email Please explain. Media Permission I give permission to Bais Chana Women International) to use photos, written quotes, audio or video of me in their promotional materials and for other non-profit purposes. Please select... Yes No Click "Next" and proceed to calculate your retreat fees. reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Need assistance with this form?