Each attendee is requested to complete this form individually (even if the mikvah will be sponsoring her attendance) in order to secure her reservation.Name(Required) First Last Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I currently work as a:(Required) Mikvah attendant Mikvah administrator Mikvah educator Please check all that applyName of Mikvah(Required)Number of years I have worked at this mikvah(Required)Please describe your mikvah educator role and list the names of the mikvaos with whom you work (if applicable)(Required)Previous Mikvah Attendant PositionsName of MikvahCityYears Add RemoveClick the + sign to add additional names.Have you previously had any formal Mikvah attendant or sensitivity training?(Required) Yes No Please elaborate:(Required)Organization/ Presenter NameDate Add RemoveOur workshop facilitators will be using real-life scenarios as examples. If you have a personal anecdote pertaining to a challenging circumstance encountered within the Mikvah context, please share it below. This may include situations that you effectively managed or areas in which you identify opportunities for enhancement. In order to safeguard confidentiality, we kindly request that any identifying details be omitted.I am attending this program:(Required) As part of a group from my mikvah and my mikvah is sponsoring my attendance As an individual participant and covering my own fee Cost: $36(Required) Price: Total Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Program attendance(Required) I understand that this is a full program and that sessions will begin and end on time in order to make the most of the day.
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