Summer Application

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Personal Information

First Name

Middle Name

Last Name

What is your nickname? (Or first name, again)

Date of Birth

mm/dd/yyyy

Cell Phone

Home Phone

Email Address

Hebrew name, if known

Mother's Hebrew Name, If known

Will you be applying for a grant?

Please check your email for a link to the Grant application.

Permanent Address

Street

City

U.S. State

Postal Code

Country

State/Province if outside of the United States

Family/Friend Who Introduced you to Snorkel & Study

Referral First Name

Referral Last Name

Referral Phone

Referral Email

Add another referral name?

Yes, please

Ref 2 First Name

Ref 2 Last Name

Ref 2 Phone

Ref 2 Email

If you heard of us another way, explain

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Relationship to you

Are you -

If other, explain

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How long have you been a single mom?

Does your child(ren) live with you?

Will you need childcare at the retreat?

Children Information

Enter the first child's name, age and gender as demonstrated below

John Doe - 6 - Male

Add another child?

Yes, please.

Enter the Second child's name, age and gender as demonstrated below

John Doe - 6 - Male

Add a third child?

Yes, please.

Enter the third child's name, age and gender as demonstrated below

John Doe - 6 - Male

If you’d like to share a room with a friend or friends, please provide their names and numbers below.

Name

Phone

Name

Phone

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Tell us about yourself

What are you most looking forward to at the retreat?

What topics are you most interested in hearing about?

Have you ever attended a Jewish learning program? If so, please list when and what.

What do you hope to gain by attending?

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Medical Information

Do have any dietary needs or restrictions? Please be specific so we can make sure to have what you need (If there are none, please write none.

Do you have any allergies, including penicillin?

Significant medical history? If so, please explain.

Will you be taking any medications when you're with us? if so, please list.

Additional comments? Anything else you'd like us to know about you?

I give permission to Bais Chana Women International to use photos, written quotes, audio or video of me in their promotional materials or for other non-profit purposes. Check all that apply:

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Please consider adding a donation to your $50 sign up fee. Every amount helps! You will be directed to the payment page once you submit this application. Then click submit, review your responses and proceed to pay.

If you checked off that you’ll be applying for a Grant, make sure to check your email for a link to the Grant application. We don’t ask for any financials, just your honest responses.

See you soon!

APPLICATION FOR AUGUST RETREAT

Sign up for the retreat in 3 easy steps:

Sign up for Jewish Single Moms' Summer Retreat

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