Edmonton Shabbaton Registration 2012 .pdf


Nom original: Edmonton Shabbaton Registration 2012.pdfAuteur: Devorah

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West Edmonton Mall Maimonides Shabbaton Registration 2012
Email:Ekollel@telus.net 780-297-2086
Last Name:
First Name:
Address:
City:
Postal Code:
Home Phone:
Cell:
Email Address
Age:
Date of birth:
Gender : Male

Female

Health Care #
Food restrictions
Are there any special medical restrictions we should be aware of?
In case of a medical emergency who would you like us to contact?
Name
Phone
Relationship to you
HOTEL RESERVATIONS
We will do our best to place you with your friends at the hotel, we can't guarantee all of your requests
will be granted, but we will certainly try! Please list below 2 people who you like to room with.
1:____________________________
2:____________________________

PAYMENT METHOD
Please bring a cheque for the amount of $60 (non-refundable )to cover costs of the Shabbaton to your
next learning session made out to UEI or you can fill out the credit card information below and your
account will be deducted accordingly.
CC# _________________________________________________
EXPIRY DATE __________________________________________
CID # ________________________________________________
Mastercard
Amex
Visa

Sign up deadline will be Monday January 30th 2012
In registering for this event, I agree to adhere to the program and observe the religious code set for the
event. I understand that my registration requires my attendance at the entire event, and I am not
permitted to leave during the program unless given permission by administration.
By checking this box I agree to the above

Signature_______________________
All communication regarding the shabbaton will be via email. Please ensure that all email addresses
are correct and that your payment information is valid.


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