ECE-RJ Israel Participant Intake Form
We are thrilled that you will be joining ECE-RJ on a trip of a lifetime! Please complete the form below by August 15, 2017. Please plan to arrive in Israel on Sunday February 18, 2018 by 1:00 pm Israel Standard Time and depart after 11:00 pm on Wednesday February 28th.

Invoices have been sent out. Please reach out to Tricia Ginis, Executive Director at executivedirector@ecerj.org or call 480-620-4053 with any questions.

Please use N/A for any answers you need to come back and fill in later. The link will be available for you to come back and update your information as you make your flight arrangements, to update passport information etc.

Please contact Heidi Baker with any questions or clarifications. hbaker@bethavodah.org or 339-364-0014

Shelly Sender, VP of Learning
Heidi Baker, Co-Chair Israel Steering Committee

First Name *
Your answer
Last Name *
Your answer
Date of Birth *
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Cell Phone Number *
Your answer
Email *
Your answer
Street Address *
Your answer
City, State, Zip Code *
Your answer
Will you need to rent a cell phone and/or purchase a sim card for your time in Israel? *
Full Name on Passport *
Your answer
Passport Number (can provide later if renewing or applying for a new passport-just note it here) **IF YOUR PASSPORT IS EXPIRING WITHIN 6 MONTHS OF TRAVEL IT MUST BE RENEWED. *
Your answer
Passport Expiration Date *
Your answer
Passport Nationality *
Your answer
Emergency Contact Name *
Your answer
Relationship to Emergency Contact *
Your answer
Emergency Contact phone number (with area code) *
Your answer
Medical Conditions *
Your answer
Dietary Restrictions *
Allergies (food, medicine and/or environmental) *
Your answer
Have you been to Israel before? *
Do you speak Hebrew? *
I plan to extend a few days PRIOR to the start of the trip *
I plan to extend a few days at the END of the trip *
For those extending: I would like additional programming/site visits coordinated as a group *
Roommate Preference- Please indicate your top 3 roommate choices OR if you would like us to pair you with a roommate. (2 people per room) *
Your answer
Hotel Room Request (single (additional fees apply or double occupancy) *
Arrival Date (arrive by 1:00 pm Sunday February 18, 2018) *
Arrival Flight Info: Airline/arrival time/flight number *
Your answer
Departure Date (depart after 11:00 pm Wednesday February 28, 2018) *
Departure Flight info: Airline/departure time/flight number *
Your answer
Comments/Questions (Please add any additional information here.)
Your answer
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