Road Trip Registration Form 2022

Pricing: $1770
After your registration is processed, you will be contacted to meet with Rabbi Yossi Denburg.
This is an interview process and should a decision be made that you will not be
participating, any monies paid will be refunded.
Click here for information regarding scholarships
Teen's Full Name*
First NameLast Name
Teen's E-mail*
Teen's Phone Number*
Area CodePhone Number
T-Shirt Size*
SMLXLXXL
Parent's Name*
First NameLast Name
Parent's E-mail*
Parent's Phone #*
Area CodePhone Number
Is the teen's mother Jewish by birth?*
YesNo
Is the teen's father Jewish by birth?*
YesNo
Are there any conversions in the family?*
YesNo
Are there any adoptions in the family?*
YesNo
Payment:*
Full Payment - $ 1770Deposit of $770, balance to be paid in 2 payments: June 15th and June 30thPayment Plan: $500 at registration, payments of $317.50 over 4 monthsPayment Plaan: $500 at registration, payments of $158.75 over 8 months
I will be apply for camp scholarship via Jewish Family Services*
YesNo
Note: If you are approved for a scholarship, it will be applied toward your last payment(s).
I would like to be a sponsor. This amount will be charged upon submission.
$5400$3600$1800
Total
$0.00
Preferred method of payments: Zelle: [email protected] or check/cash

Payment*

Credit Card Zelle / Check / Cash

Postal / Zip Code

Country

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