Southeastern  shabbaton Application Form

ONLY $99 

Teen Applicant  

First Name  Last Name   
Gender       Male        Female 
 School    Grade   
Address    City    
Zip Code  Email  
Home Phone Cell           
D.O.B.  Allergies  

Parent Info  

Father Name Mothers name   
Fathers Cell Mothers Cell
Fathers Email    Mothers Email  

Rooming Requests     
You may make up to five rooming requests, of whom you would like to room with. Late applications lessen the chance of us being able to honour your request. We will try our hardest to honour at least one of your requests.  (This year we will be hosted again by warm and welcoming Jewish families in the historic neighborhood of Crown Heights)   

Rooming Request: 1   Email  
Rooming Request: 2   Email  
Rooming Request: 3   Email  


Cost: *$99      
Billing Info:  Visa Master Card American Express
 Name on card  Card Number  
 Exp:  CVV What's This?  


I would like to help sponsor a teen who lacks the funds to participate.       

Comments / Questions                  

  • If you have any questions: Call Rabbi Shmuly G. at 561-998-5391.
  • Once your application has been processed we will e mail you with the date of the trip meeting. At this meeting we will go over the itinerary and things to bring etc…