Road trip teen registration - Wilansky 2022

Teen Info:

Date Of Birth*

Current Grade*

Before the summer

Teen Cell Phone*

Teen cell phone number only. (Parent telephone numbers below)

Email Address*

Address

Address Line 1

Address Line 2

City

State

ZIP Code

T-shirt Size*

Parent Info

Father's Name*

Phone Number*

Email Address*

Mother's Name*

Phone Number*

Email Address*

Additional Info

School Currently Attending*

Emergency Contact*

Other than Parents

Emergency Contact Phone Number*

Emergency Contact Relationship*

Medications

Allergies or other Medical conditions*

Please provide your full hebrew name and mother's hebrew name*

Comments

Road Trip Dates, Location and Cost*

Busch Gardens | August 9 - 11, 2022 | $569

Terms and Conditions

Please read carefully *

I have read the forms attached below along with a parent/guardian and I/we agree to the terms and conditions.

Parent Consent Form And Teen Code Of Conduct

Billing Information

Name on card*

First Name

Last Name

Billing Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Card Number*

Pay Now: $

Sibling Promo Code

Case sensitive

Teen Info:

The boy's registration is full for this trip.

Teen Info:

Parent Info

Additional Info

Terms and Conditions

Billing Information