2019 AIPAC Policy Conference Trip Registration form

2019 AIPAC Policy Conference Trip Registration Instructions:

1. Enter information on the form below and submit (press gray button).

2. Then click on the blue button below to sign the online release form (this is a requirement). An individual online Release Form must be completed for each student in a household.

3. A $150 non-refundable AIPAC PC tuition must be submitted with this registration. Click below on the yellow button to pay $150 online or mail payment to Jewish Education Center of Cleveland, 2030 S.Taylor Rd., Cleveland Hts., OH 44118

For Office use

Student First Name

Student Last Name

D.O.B

Grade as of September 2018

Student Phone

Student Email

School Currently Attending

Supplemental or day Schools Last Attended

Synagogue Affiliation

Youth Group Affiliation

Mother First Name

Mother Last Name

Mother Phone

Mother Email

Address

City

State

Zip

Father First Name

Father Last Name

Father Phone

Father Email

Second Address

City

Second State

Second Zip

Health Insurance Company

Subscriber Name

Relationship to participant

Subscriber ID#

Emergency Contact

Food allergies or dietary restrictions Concerns

2019 AIPAC Policy Conference Registration Form

2019 AIPAC Policy Conference Trip Registration form

Sponsored by The William and Anita Heller Family Jewish Continuity Fund

2019 AIPAC Policy Conference Trip Registration Instructions:

1. Enter information on the form below and submit (press gray button).

2. Then click on the blue button below to sign the online release form (this is a requirement). An individual online Release Form must be completed for each student in a household.

3. A $150 non-refundable AIPAC PC tuition must be submitted with this registration. Click below on the yellow button to pay $150 online or mail payment to Jewish Education Center of Cleveland, 2030 S.Taylor Rd., Cleveland Hts., OH 44118

Contact

For any inquiries please email

info@akivacleveland.org

Or Call

216.367.1388

26500 Shaker Blvd., Beachwood, OH 44122