Registration Form for ASSAF: Judaism, Health and Healing for Clinicians, January - March 2010, co-sponsored by The Kalsman Institute on Judaism and Health and the Shalom Center of Temple Chai, Phoenix

Name
Title
Institution
Address (1)
Address (2)
City
State
Zip
Office Phone
Mobile Phone
Email
Medical Specialty
Synagogue Affiliation (if applicable)
Special Accommodations (please note that vegetarian and fish options will be available for all meals and that food will be OU certified)
Form of Payment	Visa/Mastercard (You will be contacted for credit card information). Check/Money Order (See instructions below) Not Applicable

I am registering for ASSAF: Judaism, Health and Healing for Clinicians, which includes the ten-week online curriculum and access to the program website in addition to opening and closing retreats at Temple Chai of Phoenix, Arizona, as well as a private Phoenix home. This fee includes all materials, consultation, and meals, which will be catered and OU certified. All meals will be provided beginning with dinner on Friday to lunch on Sunday.*

I am not available to attend this year, but am interesting in future meetings of the ASSAF: Judaism, Health and Healing for Clinicians.

*Both lodging and transportation costs to and from Phoenix International Airport (PHX) are not included in the cost of the program.

Please mail your early registration fee of $365 (before October 30)
Or your regular fee of $395 to the:

Kalsman Institute c/o HUC-JIR
3077 University Avenue
Los Angeles, California 90007

Checks are made payable to Kalsman Institute/HUC-JIR. Please call Sharona Silverman, Temple Chai, (602) 971-1234 ext. 280 or ssilverman@templechai.com, with any questions about the program.

Your registration is due no later than December 1, 2009.