KOACH Kallah - Online Registration Form

APPLICATION FOR KOACH KALLAH
February 14 - February 17, 2013

University of Pennsylvania, Philadelphia, PA


For more information about the Kallah, visit http://www.koach.org/kallah.htm

Name
Gender Female    Male
School
Major
Graduation Year
Home Congregation
ADDRESS, IF LIVING ON CAMPUS
Street Address
City
State/Province
Zip/Postal Code
School Phone
Cell Phone

HOME ADDRESS

Street Address
City
State/Province
Zip/Postal Code
Home Phone

PERSONAL INFORMATION AND PREFERENCES

E-mail
Parents Names
Are you a vegetarian? Yes No
Vegan Yes No
Any food allergies?

Please list specific allergies:

Roommate Request
(we'll try)
Do you prefer a low floor hotel room? Yes No
Date of Birth

I'm willing to help lead the following services:

Prepare: Torah Reading
Haftarah Reading
D'var Torah
Sharing Skills or Expertise for a Workshop (eg, Israel advocacy, Music, Advanced text study, Art)
Specify:

My travel plans to/from Philadelphia are:

 

PAYMENT INFORMATION

Thanks to a generous gift from Women's League for Conservative Judaism, registration is only $100 per person. Early bird registration for University of Pennsylvania students until January 25, 2013 is $54; $64 thereafter.

Payment Method For online registrations, credit card is the only acceptable form of payment. If you wish to pay by check, we ask that you please download the printed application (PDF Format / MS Word Format) and remit by postal mail.

Type of Card

MasterCard
Visa
Discover
American Express

Cardholder Name

Card Number

(no dashes)

CV Code


For MasterCard or Visa, it's the last three digits in the signature area on the back of your card. For American Express, it's the four digits on the front of the card.

Expiration Date

-- mm/dd/yy

Credit Card Authorization

Choose from the following options (check all that apply):

  Yes, I authorize a charge of $100 to my card.

  Yes, I authorize a charge of $54 to my card (Penn Students Only; $64 after close of business on 1/25/13)

  I do NOT authorize any charges to my card.
 

Which address is
the billing address?
Home Address
School Address