Mame-Loshn'99
May 27-31 1999
 
1st Adult

First Name____________________________ 

Second Name__________________________ 

Street Address_________________________ 

City__________________________________ 

State_________________________________ 

Zip__________________________________ 

Country_______________________________ 

Phone_________________________________ 

Fax___________________________________ 

E-mail_________________________________

2nd Adult

First Name____________________________ 

Second Name__________________________ 

Street Address_________________________ 

City__________________________________ 

State_________________________________ 

Zip__________________________________ 

Country_______________________________ 

Phone_________________________________ 

Fax___________________________________ 

E-mail_________________________________

If there are additional adults in your party, please include them on a separate sheet of paper.

Children:

Children's Names/Ages________________________________________

Emergency Contact___________________________________________
 

Type of Accommodation (Please Check)

Lippincott Residence Hall Linen_____ Non-Linen_____

Newell Apartments Linen_____ Non-Linen_____
 
Commuter _____ 

Need a ground floor apartment _____

Full Conference _____ 

Kosher meal _____

Day Ticket _____

Registration Fee $____________

Bus$_______________________

Enclosed $__________________
 

Please enclose a check for the full reservation made payable to Mame-Loshn. Mail to:
      Mame-Loshn '99
     110-64 Queens Blvd.
     Forest Hills, NY 11375

Mame-Loshn Scholarship Fund (helps bring students and families to Mame-Loshn)  $_____
Please write a separate check, payable to Mame-Loshn. Indicate that it is a contribution. Thank you.