2018-19 OSU Trip Registration Form

2018 OSU Visit

Registration Form

Instructions:

Fill out a registration form for each student.
Enter information on the form below and submit (press gray button).
Then click on the blue button below to sign the online release form (this is a requirement).
For Questions, please contact Tina Keller.

For Office use

Student First Name

Student Last Name

D.O.B

Grade as of September 2017

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

@akiva

2018-19 OSU Trip Registration Form

2018 OSU Visit

Registration Form

Sponsored by The William and Anita Heller Family Jewish Continuity Fund

Instructions:

Fill out a registration form for each student.

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

Then click on the blue button below to sign the online release form (this is a requirement).

For Questions, please contact Tina Keller.

contact us

26500 Shaker Blvd., Beachwood, OH 44122

216.367.1388

info@akivacleveland.org