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Email
Home Phone Cell Phone
Best time to contact you (in your home time zone)
Birthday Single Married Divorced Marital Status
Who referred you to Bais Chana?
Phone number of the person who referred you
Which session are you registering for? (i.e., Key Largo, Jan 07; Berkshires, April 07; Twin Cities, Aug 07)
Date of Arrival Date of Departure Private Double Triple Student Select Room Type
If you are requesting a double or triple room to share with friends, please provide their name(s) and contact numbers. If you do not have friends attending, we will assign roommates for you.
Name Contact Number
Name Age
Your responses below will help us make your learning experience optimal.
1. Describe your previous learning experiences, if any (names of programs, dates of attendance).
2. How would you characterize your Hebrew reading?
3. What you are most interested in studying?
4. What do you hope to gain by attending?
5. Additional comments? Anything else we should know about you?
Please complete the following so we can best accomodate your needs:
Do you have any special dietary requirements?
List any allergies, including Penicillin.
Significant medical history? Are you currently taking any medications?
