.htm_cmp_Arctic000_hbtn.gif){kind=small}
Mercaz Sub Regional Chapter Presidents Weekend
September 19- 21, 2008
*Convention begins Friday at 4:30pm and ends Sunday at 12pm
Hosted at Rodeph Sholom, Tampa, Florida
Cost $90(make checks payable to Rodeph Sholom
Deadline August 29, to Rodeph
Mail to Rodeph Sholom
Attn: Judy VanDerStelt
2713 Bayshore Blvd.
Tampa, Fl 33629
Name ______________________________________ Chapter ___________
Address _______________________________________________________
City _____________ State ___ Zip _________
Gender _M _F Grade ___
Home Phone Number _______________ Email _______________________
USYer’s Cell Phone ____________________________________________
Parents’ Names ________________________________________________
Contact person in case of emergency (other than parent)
Name ____________________ Phone # ______________
Relationship ______
Sweatshirt Size __ S __ M __ L __ XL __ XXL
Check one:
__No __Yes Vegetarian? if yes will you eat chicken, eggs, fish (circle those that apply)
__No __Yes Walking Distance Required
__No __ Yes Any allergies and or/ restrictions? if yes, please list ____________________
List 2 USYers you would like to room with, in order of preference:
1. Name __________________________________ Chapter __________________
2. Name _________________________________ Chapter __________________
Every effort will be made to honor mutual requests.
Requests will only be considered if forms are received on time.
WE have read the application and attached rules and regulations and the applicant agrees to abide by the rules of this convention.
WE understand that any infraction could result in being sent home from convention at your expense.
Applicant’s Signature ____________________________________ Date ________________________
Parent’s Signature ____________________________________ Date __________________________
For more information please contact
Stephanie Nichol at the regional office 561-372-0420 or nichol@uscj.org
or Mercaz President, Rebecca Geboff at rebgeb@cfl.rr.com