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APPLICATION FORM

Please fill out all the required fields of the form

REGISTRATION FOR THE MAY TRIP IS FULL

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 *

HOW DO YOU WANT YOUR NAME SPELLED ON YOUR NAME BADGE *

First

Last

Emergency Contact

Name *

Relationship to Applicant *

Phone number of emergency contact *

email address of emergency contact *

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

I agree to participate in all the programming while I am on the trip in Poland *

YES

By clicking SUBMIT, your application will be submitted and you will be directed to our payment site to
make the $399USD deposit. Your application is not complete until the deposit has been paid.
NOTE: DO NOT BOOK YOUR FLIGHT UNTIL YOU HAVE WRITTEN CONFIRMATION FROM US

Submit