Quad Region Retreat 2022

Your Name*

First Name

Last Name

Nickname or First Name for your Badge

Phone Number*

Phone Type*

Cell Home Work

Phone Number 2

Phone 2 Type

Cell Home Work

Email*

Confirm Email *

Address*

Address Line 1

City

State

ZIP Code

Emergency Contact's Name*

First Name

Last Name

Emergency Contact's Phone*

Have you been to an FJMC Convention or Regional Retreat previously?

Yes No

Select your FJMC Region

Hudson Valley Middle Atlantic New York Metro Northern New Jersey

Your Men's Club (Synagogue)*

Your Men's Club City & State*

If you are a Regional or Club officer please list here. If not, leave blank.

All participants are required to be
Covid-19 Negative Two Ways:

1.
Bring results of a negative Covid-19 PCR test
taken no more than 72 hours prior to arrival at the camp.

2.
Have a negative rapid Covid-19 test result upon arrival at camp.

Camp Zeke may require wearing masks, social distancing
and other similar measures as required by
relevant state orders and regulatory guidance.

I have received the full Covid-19 vaccinations and at least one booster.*

Yes

I will bring proof of a negative Covid-19 PCR test taken no more than 72 hours prior to arrival at the Retreat.*

Yes

I will take a rapid Covid-19 test upon my arrival at camp. I understand that I will only be admitted to Camp Zeke if I have a negative test result.*

Yes

Sweatshirt Size

S M L XL 2XL 3XL

I am a

Kohen Levi Yisrael

I am able to

Lead Services Read Torah Read Haftorah Hebrew Reading English Reading None

Please specify services (or service parts) you can lead and/or Hebrew prayers you can read?

Special Dietary Restrictions

Camp Zeke is a Glatt Kosher facility.

Roommate Request (not guaranteed)

THE CREDIT CARD PAYMENT SECTION WILL APPEAR
AFTER YOU SELECT YOUR REGION ABOVE & AFTER YOU MARK
QUANTITY OF "1" IN THE REGISTRATION BOX THAT WILL APPEAR BELOW.

I'm registering from the Hudson Valley Region

$340 -$100 Regional Rebate = $240

$ 240.00

Quantity:

I'm a First-Timer registering from the Hudson Valley Region

$340 - $200 First-Timer Regional Rebate = $140

$ 140.00

Quantity:

I'm registering from the Middle Atlantic Region

$340 -$200 Regional Rebate = $140

$ 140.00

Quantity:

I'm registering from the New York Metro Region

$340 -$241 Regional Rebate = $99

$ 99.00

Quantity:

I'm registering from the Northern New Jersey Region

$340 -$60 Regional Rebate = $280

$ 280.00

Quantity:

I'm a First-Timer registering from the Northern New Jersey Region

$340 -$160 First-Timer Regional Rebate = $180

$ 180.00

Quantity:

Single Room request

$ 100.00

Quantity:

Refrigerator in Room

$ 25.00

Quantity:

Credit Card TOTAL* $

Name on Credit Card*

First Name

Last Name

Credit Card*

This form is secured by Stripe online payment processing. Don't forget to enter your 3-Digit CVC code.

Billing Address*

Address Line 1

City

State

ZIP Code

11th Quad-Region Biennial Retreat
Camp Zeke, Lakewood, PA

June 10-12, 2022

11th Quad-Region Biennial RetreatCamp Zeke, Lakewood, PA

June 10-12, 2022

11th Quad-Region Biennial Retreat
Camp Zeke, Lakewood, PA