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APPLICATION FORM

Please fill out all the required fields of the form
(one application per person)

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 $575 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? *

Pricing

Age: 20 - 29 - $899 USD + Flight | Age: 30 - 44 - $1,349 USD + Flight | Age 45 + $1,849 + Flight
The true land cost of the trip is $2,150 USD per participant. The trip is being generously subsidized by individuals and organizations who deeply connect with The Living Legacy Experience and its mission. If you are able to help offset these costs and pay the full amount, please select YES.

Select One *

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