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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
*
Select
Female
Male
Date of Birth [mm/dd/yyyy]
*
Country of Birth
*
Address
*
City
*
Postal Code
*
Email
*
Cell #
*
Marital Status
*
Select
Married
Separated
Divorced
Single
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?
*
Select
Living Legacy Alumni
From a friend
Social media
Print ads
Other
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
[object Object]
Emergency Contact
Name
*
Relationship to Applicant
*
Phone number of emergency contact
*
email address of emergency contact
*
Jewish Background
Jewish Education
*
Select
Supplementary Hebrew School (Pre-age 10)
Supplementary Hebrew School (Post-age 13)
Jewish Day School
Yeshiva High School
Virtually None
Current Jewish Affiliation
*
Select
Reform
Conservative
Orthodox
Unaffiliated
Reconstructionist
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
*
YES
NO
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?
*
Select
Yes
No
Do you have any special dietary requirements?
*
Select
Yes
No
do you have any accessibility restrictions?
*
Select
Yes
No
If yes, please elaborate
*
If yes, please elaborate
*
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.
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
Home
About
Interest Form
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