Jewish Alcoholics, Chemically Dependent Persons
and Significant Others

of Florida
 

The following registration form must be completed and sent,
with full fee enclosed to:

JACS of Florida
c/o Rabbi Nahum Simon
8358 West Oakland Park Blvd., Suite 203-C
Sunrise, FL 33351

Please answer all questions.  Information is used for this JACS Retreat only.

Name _______________________________________________

Address _____________________________________________

City ___________________________ State ____ Zip_________

Tel: (day) ________________ (evening)_____________________

Email ____________________________
 

Is this your first time at a JACS retreat? _________

Would you like a buddy?   Yes    No  

I would like to lead a workshop or meeting.  Which fellowship? ______________________________

I would like to room with? __________________________________________________________

If we need to assign you a roommate:  Are you a Sabbath observer? Yes   No            Do you Smoke?  Yes   No

Are you bringing a nursing baby in arms?  Yes    No

Will you need a ride from the airport?        Yes    No

Fee enclosed $_______________

Mastercard/Visa: _________________________________

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