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APPLICATION FORM

Please fill out all the required fields of the form

Contact Information

* Indicates required field

First Name *

Last Name *

Gender *

Date of Birth [mm/dd/yyyy] *

Country of Birth *

Address *

City *

Postal Code *

Email *

Cell # *

Marital Status *

WHO WOULD YOU LIKE TO ROOM WITH? *

Who else are you travelling with? *

Do you require a single room? (Single room supplement is $495 USD) *

Yes No

What is your relationship to the requested roommate? *

How did you hear about The Living Legacy Experience? *

Passport Information

Passport Number *

Expiry Date [mm/dd/yyyy] *

Name(s) as appears on Passport *

Passport Country of Issue *

Emergency Contact

Name *

Relationship to Applicant *

Phone Number *

Jewish Background

Jewish Education *

Current Jewish Affiliation *

Are you a member of a synagogue? *

If yes, which one? *

Was your father born jewish? *

Was your mother born Jewish? *

Olami/Mosaic Funding

Olami is funded in part by Mosaic United.
Please choose yes if you want to be contacted regarding future Mosaic sponsored-opportunities.

Select One *

With programs in over 30 countries, Olami and its funding partners sometimes use independent verification firms to assure that programs are attended and impactful. By registering, I understand that I might be contacted by a verification firm for quality control purposes.

Choose Any *

YES

Special Requirements

Are you currently taking any medications? *

Do you have any special dietary requirements? *

do you have any accessibility restrictions? *

If yes, please elaborate *

Is this your first time travelling to Poland on an organized trip? *

Priority will be given to those travelling for the first time

By clicking Submit your application will be submitted and you will be directed to our payment site to make the $300US deposit. Please note that your application is not complete until the deposit has been paid.

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