Riverdale Y Maccabi ArtsFest Registration

Art specialitiy:
[ ] Acting/Improv
[ ] Creative Writing/Journalism
[ ] Rock Music
Y Member? Yes Membership # _____________________________________________ [ ] Musical Theater
Registration Information (please print) [ ] Jazz Ensemble
[ ] Visual Arts
Participant: [ ] Dance
Name ___________________________________________________________________________________ [ ] Vocal Music
(last) (first) (MI) [ ] Film and TV Production
Address _________________________________________________________________________________ [ ] Sports Broadcasting

City ________________________________________________ State ________ Zip ___________ Kosher home hospitality required? [ ] yes [ ] no

Birthdate ____________________________ Sex: M ___ F ___

School currently attending ________________________________ School as of Sept. '10 ______________________________________ Grade Sept. '10 _________

Parent #1's name _________________________________________________________________________ date of birth ______________________

Phone (day) ________________________________________________________________ (eve) __________________________________________

Cell phone ________________________________________________________________

email ____________________________________________________________________________________________

Parent #2's name _________________________________________________________________________ date of birth ______________________

Phone (day) ________________________________________________________________ (eve) __________________________________________

Cell phone ________________________________________________________________

email ____________________________________________________________________________________________

Emergency Information
Emergency Contact ___________________________________________________________________________________________________________
(please list someone other than parent)
Telephone _____________________________________________________________ Relationship _____________________________________________________
Family physician _______________________________________________________________ Telephone _______________________________________________
Trans. #
Registration fee: $1,300 / $1,100 for Riverdale Y members
___________
Includes registration, housing, transportation, meals, and, of course, JCC Maccabi ArtsFest t-shirt!
___________ Registration fee $ ____________
___________ Contribution: These fees do not reflect the real cost of these programs.
The Riverdale Y and UJA/Federation Please help us by including an additional tax-deductible gift $___________
of NY reserve the right to use
photos taken for publicity purposes. The Riverdale Y's Federal ID # is 13-1740507. Total $___________

5. Payment
Please charge my ________Visa _________Mastercard Card # (req'd): _____________________________________________________

Name (as it appears on card) Please print _______________________________________________________ Exp. date (req'd) ____________

Signature (req'd)____________________________________________________________________________________________________
I agree to pay above total amount according to card issuer agreement (merchant agreement if credit voucher)

Check for $________________ (made payable to Riverdale YM-YWHA) Your check will be your receipt. There is a $25 charge for returned checks

For Office Use Only

Date received ________________ Rec'd by __________________ Date processed ______________ Processed by _________________

Circle one: Cash Check Charge Total paid $___________ Check # _________ Batch # _____________

Questions? Call us at (718) 548-8200 /Fax (718) 796-6339

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