Registration

Please complete one registration form per family. A deposit of $100 per person is due upon registration with the balance of payment due July 15, 2012. We look forward to receiving your application and welcoming you to KlezKanada 2012! Please don't hesitate to contact us with any questions.

*(denotes required field)

First Name: *

Last Name: *

E-Mail Address: *

E-Mail Address again: *

Please enter your E-mail Address a second time.

Street Address/City/Province/Country/Postal Code

Full Address *

Primary Phone Number *

Cell Phone Number

Emergency Contact *

Total Attending *

Please provide full names for each registrant and ages for any registrant under 17

List of Registrants *

Please check if you wish to register

KlezKanada Poetry Retreat

Prices are per person. For accomodation details, please refer to descriptions at the top of the page.

Accomodations *

13-16 years old deduct per child $75, 12 years and under deduct per child $100, Under 5 years no charge

Deductions

Please let us know how you will be arriving

Travel Plans *

Will you need a shuttle from Montreal to Camp B'nai Brith? $20 per person.

Shuttle Service to KlezKanada *

Will you need a shuttle from Camp B'nai Brith to Montreal? $20 per person.

Shuttle Service from KlezKanada *

Check all that apply

Dietary Requirements *

None
Vegetarian
Vegan
Lactose Intolerant
Gluten Intolerant
Other

Are there any other medical problems that we should be aware of?

Medical

How would you prefer to pay?

Total *

How would you prefer to pay?

Payment *

Cheque (please mail)
Credit Card (please contact us - see sidebar for contact details)

CAPTCHA Code: *

Registration

Accomodation Prices and Payment