Name:

Full Address:

Telephone

Primary telephone

Secondary telephone (optional)

Course Participation

Internet: Yes          No

Face to Face: Yes       No

Note: You are welcome to participate even if you are able to participate in either the Internetor or face-to-face portion of the course, but not both.

E-mail Address

Note: You must have a working e-mail address in order to participate in the Internet portion of the course.

Are you a member of a synagogue or chavurah? Yes       No

If yes, what is the name and city/state where your synagogue is located?

Synagogue/chavurah denomination (please check):