Registration 1 Your Info2 Payment Chazkeinu welcomes all Jewish women who are struggling with mental health challenges and female family members of those who are struggling. Note: This Shabbaton is for Chazkeinu members only, not their children or spouses. All information will be kept strictly confidential and only used for Shabbaton registration purposes. Name* First Last Badge Name*The name you would like to appear on your name tagDate of Birth* MM DD YYYY (must be 18 or older to attend)Please select your age group (for housing purposes)*18-2021-3031-4041-5051-6061-7071+Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email Enter Email Confirm Email (if provided, you will receive additional required forms via the email address you provide)Additional required forms will be sent to you via email. Please check if you DO NOT have access to email and need to receive all necessary forms at your mailing address provided above. I DO NOT have access to email Best way to reach you*PhoneTextEmailWould you like to be included (by first name only) on a Shabbaton contact list to be distributed at the event?YesNoYou must be on the contact list in order to receive a copy of the contact list at the shabbaton.Emergency Contact: Do you wish to provide contact information for someone we may call in case of an emergency?*YesNoEmergency ContactEmergency Contact Name*Emergency Contact Phone*Emergency Contact Relationship*Emergency Contact Authorization*I authorize anyone on Chazkeinu staff to call my listed Emergency Contact in case of an emergency. I authorize Chazkeinu to release and obtain any and all pertinent details that my emergency contact needs to know about me. I agree Professional ReferencesYour Therapist/Doctor's Name*Please note: Your registration is not finalized without therapist approval.Your Therapist/Doctor's Phone*Your Therapist/Doctor's Email A Few QuestionsHousing - If you want to arrange your own housing please check here. I will arrange my own housing Roommate RequestsPlease let us know with whom you'd like to share a room. We will do our very best to honor your request.Allergies you feel we should know aboutAdditional commentsWhat are some topics that you would like to see included in the workshop discussions at the Shabbaton?We are having a Chazkeinu sisters talent show!Yes, I would like to participateNo thanksWhat would you like to perform?Do you sing? Can you draw a picture without looking? Do you have a story to tell? Can you make people laugh? Can you guess where people are from based on accent alone? Whatever your talent, we’re excited for a fun evening - show us what you’ve got!Who will you be performing with?I am performing aloneI will find others to perform with meI would like to be paired with another participantToday's Date You will receive a letter with important shabbaton guidelines for you to sign and a letter to be completed by your therapist. Therapist approval is required for participation in the Shabbaton. We will not be contacting therapists this year. It is solely your responsibility to have your therapist sign the form and return it to us. Please note: Your application is not yet finalized. All forms must be completed and returned to us (via email - [email protected] or snail mail Chazkeinu 2832 W. Touhy Chicago IL 60645) prior to December 2, 2018. You will be notified via your best method of contact if your application has been accepted If you don’t hear from us by Dec 5th, please call 845-640-1466 or email [email protected] to check on the status of your application Payment Preference*Credit CardCheckCashLength of Stay*Full Shabbaton Fri through SundayShabbos OnlySat night and Sunday onlySat night onlySunday onlyIf you have raised $350+ for Chazkeinu, your shabbaton fee will be waived. Have you raised $350?YesNoTotal $0.00 Discount CodeCredit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Check InfoPlease send a check made out to Chazkeinu to: 2933 W. Jerome Chicago, IL 60645.