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J Street 5th National Conference
March 21-24, 2015 Washington, DC
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ATTENDEE INFORMATION
First Name
*
Your answer
Last Name
*
Your answer
Salutation (Mr., Mrs., Dr., Ms., Miss, Rabbi)
*
Your answer
Name as you wish it to appear on badge (please include any applicable title)
*
Your answer
Organization name (if applicable)
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip (9 digits)
*
Your answer
Email
*
Your answer
Business phone
Your answer
Mobile phone
Your answer
Home phone
Your answer
Fax
Your answer
SURVEY INFORMATION
I want my J Street organizer to get in touch with me about opportunities to get involved:
Yes, please contact me.
If you require accessible accommodations, please indicate:
Sign language
Large print
Braille
Other:
Have you attended a previous J Street National Event?
*
October 2009: Driving Change, Securing Peace
February 2011: Giving Voice to Our Values
March 2012: Making History
September 2013: Our Time to Lead
June 2014: J Street National Summit
First Time Attendee
Required
How did you hear about the conference?
*
J Street Website
Email from J Street
From a friend
At my place of worship
On campus
Via phone call
From a participating organization
Through social media
Other:
Required
Were you encouraged to register for this conference by another J Street supporter? If so, please list their name:
Your answer
Will you pledge to bring a new person to the conference?
Yes!
Are you a Rabbi, Cantor, Rabbinical or Cantorial student?
Yes
Are you a Hillel Professional?
*
Yes
No
Required
If you are a member of a synagogue or congregation, please list its name here:
Your answer
Would you be interested in attending an afternoon prayer service (mincha) during the conference? If so, please indicate your preference:
Egalitarian
Mechitza
Please select your age bracket below:
*
17 or younger
17-22
23-29
30-39
40-49
50-59
60-69
70 or older
Required
If you attended a college or university, please list the name of the institution:
Your answer
Please indicate your current status (if you are a current undergraduate student, please use Student Registration)
Alumnus
Current Graduate Student
Please provide your twitter handle:
Your answer
I understand that my photo may be taken and used on a website or brochure:
*
Yes
Required
GALA INFORMATION
Are you interested in attending the Gala Dinner?
Yes
No
Please provide me with more information
Meals are kosher-style. Please indicate if you require:
Strictly kosher
Vegetarian
Vegan
Not applicable
Please list any food allergies or dietary restrictions you might have:
Your answer
Please list the full names of those whom you wish to be seated with:
Your answer
ADVOCACY DAY
Join hundreds of your fellow activists for J Street's Fifth Advocacy Day. Meet with Members of Congress on Capitol Hill to advocate face-to-face for US leadership toward a two-state solution. Advocacy Day will take place on Tuesday, March 24, from 9:00am - 4:00pm and is of no cost to you.
Will you commit to join us for the 2015 Advocacy Day?
*
Yes, I commit to attend
No, I cannot attend
Required
TICKET INFORMATION
*
Should you need financial assistance, please contact
financialassistance@jstreet.org
Conference Ticket 30% off $245
Conference Ticket 40% off $210
Conference Ticket 50% off $175
Gala Dinner Only Ticket $250
Young Professional Gala Dinner Only Ticket $100
Financial Assistance Ticket $150
Financial Assistance Ticket $100
Financial Assistance Ticket $50
Financial Assistance Ticket $36
Other:
Required
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