Shabbaton Registration 2021 1 2 3 Chazkeinu welcomes all Jewish 18 and older 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. Note: There will be a $50 late fee for any applications after May 10th. Applications will not be accepted after May 14th. 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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 Relationship*Emergency Contact Phone*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 QuestionsWould you like to request a roommate? (Please give 3 top choices) Yes Please note: While we will try our best to accommodate we can't guarantee what roommates you will have.Roommate Request 1st ChoiceRoommate Request 2nd ChoiceRoommate Request 3rd ChoiceAre you looking for a ride for the Shabbaton? Yes Please choose which neighborhood is closest to you and we will inform you if there are group rates or rides available:* Boro Park Monroe Monsey Lakewood Five Towns Are you able to offer a ride? Yes From where? (Location)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 “show and tell” activity where we ask that you bring something small along that has meaning to you and you can share with your Chazkeinu Sisters to get to know you even better 🙂Yes, I would like to participateNo thanksToday's Date Date Format: MM slash DD slash YYYY 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 please 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 3402 Hatton Road, Pikesville, MD. 21208 ) prior to May 10, 2021. You will be notified via your best method of contact if your application has been accepted. If you don’t hear from us by May 5th, please call 781-4-SHABAT (781) 474 -2228 or email [email protected] to check on the status of your application Payment Preference*Credit CardCheckCashShabbaton Weekend* Price: $200.00 If you have raised $350+ for Chazkeinu, your shabbaton fee will be waived. Have you raised $350?YesNoTotal $0.00 Discount Code Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Check InfoPlease send a check made out to Chazkeinu to: 3402 Hatton Road Pikesville, MD. 21208 We eagerly look forward to greeting you there. Please click here to download and print important shabbaton guidelines for you to sign and a letter to be completed by your therapist (4 pages) Or you can open the attached document. 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 3402 Hatton Road Pikesville, MD. 21208 prior to May 10, 2021. If you don’t hear from us by May 5th, please call 781-4-SHABAT or email [email protected] to check on the status of your application.