1. Name
2. Address
3. Home phone
4. Email address
5. Business phone
6. Fax number
7. Mobile phone
8. Medical specialty
9. Level of learning:
I can learn from original (non-English) text	yes no
I can learn with chevruta	yes no
I require a tutor	yes no
10. I need help in finding lodging for the Yarchei Kallah	yes no
11. I am interested in CME credit	yes no

All sessions (except as noted) will be held at The Detroit Kollel

Questions? Please call Dr. Steven Tennenberg (248-968-1464, evenings/home or 313-576-3971, daytime/office)

or

Dr. Gabe Sosne (248-336-8151, evenings/home or 313-557-7630, daytime/office)

Registration fees:
Physicians: until May 3:	$400.00
Lay-persons:	$250
after May 3:	$475
Rabbis and Chaplains:	$100

Completed forms and accompanying fees (checks payable to Jerusalem Center for Research) may be sent or brought to:

Dr. Steven Tennenberg,
14641 Sherwood Court,
Oak Park, MI 48237

I am / am not (please circle) able to house (___#) of out of town participants.