JDRC/ Rutgers ASB 2016 Participant Registration
Please fill out this form so that we have all of the necessary information prior to the start of our trip
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First Name *
Last Name *
Middle Initial *
Graduation Year *
Current Street Address 1 *
Current Street Address 2
Current City Name *
Current State Initials *
Current Zip Code *
Permanent Street Address 1 *
Permanent Street Address 2
Permanent City Name *
Permanent State Initials *
Permanent Zip Code *
Cell Phone # *
School Email Address *
Alternate Email Address (Please provide a non school-based address, e.g. @gmail.com) *
What is your birthday? *
MM
/
DD
/
YYYY
Gender (I Identify as:) *
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Email *
Do you have any allergies (food or otherwise)?
Do you have any limiting medical conditions?
Select the food options that best describe your eating habits *
Please check all that apply. If you have any further needs, please list them in the other category.
Required
Will you need a special room key for Shabbat?
If you answered yes, please let us know what your Shabbat observance looks like
Is your Tetanus vaccine current? (Call your physician for records) *
Health Insurance Policy and Number *
TShirt Size *
Please share with us any special skills that you have that you would be willing to share with us on the trip
i.e. videography, photography, blogging, leading yoga, leading group activities, etc.
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