Sign up in 3 easy steps:

1.

Fill in the sign up below to complete the online application.

2.

Submit and pay your $50 application fee. (Have your credit card ready.)

3.

If you're applying for a Retreat Grant for yourself or a Childcare Grant, make sure to check that off on the application. You'll receive an email with a short form to complete.

Sign up for Single Jewish Moms Connect, Fall Retreat

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 November 2019 [Thurs-Sun] -- Westhampton Beach, Long Island, NY

Page 1
Personal Information





mm/dd/yyyy






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







Who referred you to Single Jewish Moms Connect or Bais Chana?










Emergency Contact Information





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Children Information

John Doe - 6 - Male


John Doe - 6 - Male


John Doe - 6 - Male
If you’d like to share a room with a friend or friends, please provide their names and numbers below.




Page 3

Tell us about yourself




Page 4

Medical Information






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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!

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Payment Information






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