SHOMREI TORAH MARCH OF THE LIVING APPLICATION 2018
Dear Applicant,

As you fill out the following application, please be assured that all information will be protected by The International March of the Living and Shomrei Torah Synagogue.

An application must be completed by each individual and will need to be completed in one sitting.

In order for an application to be considered, you will need to submit a $500 deposit. The deposit is fully refundable if cancelled prior to September 15, 2017. If cancellation occurs between September 15th - October 15th an administration fee of $200 per person will be deducted. After October 15th the deposit is not refundable. In November, you will be sent a statement for your travel costs and payments are due in full by Dec. 1, 2017. *** Please note that these dates are subject to change

Have your health insurance card, emergency contact information, passport number and expiration date available prior to beginning the application. (If you do not have a passport or need to renew it, you will be able to complete the application by following the instructions in the passport section)

Upon completion, you will see a prompt to submit the following 2 items:
1. Deposit of $500 made out to "Shomrei Torah Synagogue". Write the name of the applicant and MOTL on the bottom of the check. No application will be considered without a deposit.
2. Copy of the front page of your passport that shows all of your identification information and your photo.

Mail these items to:
Shomrei Torah Synagogue
Attention: Allison Spivack
7353 Valley Circle Blvd.
West Hills, CA 91304

Once your application is submitted, you will receive an email with confirmation of your answers to the email address you provided.

We highly recommend that you purchase trip cancellation and travel insurance.

Questions? Email Allison Spivack at aspivack@stsonline.org or call 818.854.7650

Email address *
PERSONAL INFORMATION
Last name (as it appears on your passport) *
Your answer
First name (as it appears on your passport) *
Your answer
Middle name (as it appears on your passport) *
Your answer
Nickname (name you prefer to be called - will appear on your name badge)
Your answer
Hebrew Name
Your answer
Date of Birth *
MM
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DD
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YYYY
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Country of Residence *
Your answer
Cell Phone *
Your answer
Home Phone
Your answer
Marital Status *
Spouse/Partner Name (If Applicable)
Your answer
With which denomination of Judaism do you most identify?
Your answer
Are you a member of Shomrei Torah Synagogue? *
If not, what is the name of the Synagogue you belong to?
Your answer
List your Jewish Organizational Affiliations:
Your answer
Are you or any of your immediate family members survivors of the Holocaust? *
If yes, please list your relationship, their names and where they were from:
Your answer
Did you lose any close family relatives in the Holocaust? *
If yes, please list your relationship, their names, where they were from and where they were murdered:
Your answer
Have you been to Poland before? *
Have you been to Israel before? *
What languages do you speak? *
Required
PROGRAM & FLIGHT INFORMATION
The Shomrei Torah Adult March of the Living Delegation full program is one week in Poland and one week in Israel. The cost of the full program includes all flights from NY, hotels, meals and transportation during the trip. Flights from LA to NY and back to LA are the responsibility of each individual participant.

All fees are based on double occupancy, with a minimum of 35 participants.

Program applying for *
Additional Services - Pricing Info not yet available but will be soon. *
Deviation Flight, Requested Date of Return, 1st Choice [Additional $200]
If you are interested in extending your trip in Poland or Israel, please indicate your first choice return date below:
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DD
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YYYY
Deviation Flight, Requested Date of Return, 2nd Choice [Additional $200]
If you are interested in extending your trip in Poland or Israel, please indicate your second choice return date below:
MM
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DD
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YYYY
Roommate Preference Poland *
Roommate Preference Israel *
For Double Occupancy *
Name of Preferred Roommate (if applicable)
Your answer
What size March of the Living jacket would you like? [Men's sizing - run large] (Subject to availability) *
What size t-shirt would you like? (Men's sizing) *
PASSPORT INFORMATION
IMPORTANT: In order to depart the US, Homeland Security requires that you have a valid passport that is valid for at least six months after the trip; accordingly, be sure that your passport expires after October 23, 2018. If it expires prior to that date, you will need to renew your passport now - do not wait. If you are awaiting a new passport, enter your old passport number or 123456789 as your passport number and your expiration date or 01/01/2018 as your expiration date. As soon as you receive your new passport, submit the inside page to us so the information can be corrected in our system.
Primary Country of Citizenship *
Your answer
Name as it appears on your Primary Passport *
Your answer
Primary Passport Number *
Your answer
Expiration Date of Primary Passport *
MM
/
DD
/
YYYY
Are you a Citizen of Israel? (If yes, please note that you must enter Israel on your Israeli Passport) *
Israeli Passport Number (If applicable)
Your answer
Israeli Passport Expiration Date (If Applicable)
MM
/
DD
/
YYYY
Secondary Country of Citizenship, other than Israel (if applicable)
Your answer
Name as it appears on your Secondary Passport, other than Israel (if applicable)
Your answer
Secondary Passport Number, other than Israel (if applicable)
Your answer
Expiration Date of Secondary Passport, other than Israel (if applicable)
MM
/
DD
/
YYYY
HEALTH INSURANCE
Health Insurance Company Name *
Your answer
ID Number *
Your answer
Group Number (If Applicable)
Your answer
MEDICAL INFORMATION
Please be honest in completing this information, as it may be important in the event we need to seek medical attention for you. The following information will be held in strict confidence: however, it will enable trip organizers to plan activities on a daily basis and to respond appropriately in case of a medical emergency. International March of the Living, Inc, hereby confirms that it will maintain all appropriate confidentiality with regard to the personal and private medical information and records provided to the International March of the Living.
If you are taking any medications now, list them below with (a) Dosage in MG, (b) Prescribing Physician, and (c) Condition the medication is treating. If you are not taking any medication, please indicate none. Example: Claritin 10mg 2x/day/Dr. Smith/Allergies *
Your answer
Please indicate any of the medical conditions listed below which apply to your medical history *
Required
If you checked any of the above, please give details including name(s), date(s) and physicians or hospitals. If you checked none of the above, please list all contact information of your personal physician for emergency purposes:
Your answer
List any allergies. Include drug, food and environmental, including insects. If none, please indicate so *
Your answer
Do you wear: *
Required
Do you carry an epi-pen? *
Indicate any hospitalizations in the last 2 years and indicate the reason and dates. If none, please indicate so *
Your answer
The March of the Living is a very emotional experience. If you have had a significant death or other traumatic loss in the last 2 years that you feel we should know about, please describe it below:
Your answer
I certify that I am able to fully participate in the March of the Living program, understanding the trip may be strenuous and that I will undergo different sleep and eating patterns based on time-zone changes, frequent bus travel, possible numerous consecutive hours on my feet and walking and may experience psychologically difficult moments. By placing your name below, you confirm that you understand the physical and mental challenges of the experiences in visiting death camps and other sites in Poland and state that you accept responsibility for your own conduct and confirm your ability to participate in the March of the Living and that you are in agreement with this statement. *
Your answer
DIETARY PREFERENCE
Due to the massive scale of the March of the Living program, please note that, unfortunately, it is not always possible to meet special dietary needs. Participants with restricted diets are encouraged to pack appropriate, non-perishable food. However, if you have dietary restrictions that you would like us to know about please list them here:
Your answer
EMERGENCY CONTACTS
Primary Emergency Contact Full Name (Cannot be someone traveling on the trip with you) *
Your answer
Primary Emergency Contact Relationship *
Primary Emergency Contact Cell Number *
Your answer
Primary Emergency Contact Home Phone *
Your answer
Primary Emergency Contact Email *
Your answer
Secondary Emergency Contact Full Name (Cannot be someone traveling on the trip with you) *
Your answer
Secondary Emergency Contact Relationship *
Secondary Emergency Contact Cell Number *
Your answer
Secondary Emergency Contact Home Phone *
Your answer
Secondary Emergency Contact Email *
Your answer
APPLICANT AGREEMENT & UNDERSTANDING
1. The undersigned intends to participate in the March of The Living (“The March”) with Shomrei Torah ("Shomrei"). In connection with his or her participation, the undersigned hereby agrees to abide by the rules and regulations of The March.

2. The undersigned is providing medical information to the leadership of The March and Shomrei on the forms enclosed with this Applicant Statement. The undersigned represents that all of the information contained in such forms is true and correct. The undersigned has read the Medical Form and agrees to abide by the conditions contained therein. All medications taken by the undersigned are detailed on the medical form or in any letters accompanying the medical form. The undersigned hereby authorizes the leadership of The March to obtain treatment for him or her as it, in its sole and absolute discretion, deems necessary and advisable. The costs of any medical treatment provided shall be the responsibility of the undersigned.

3. The undersigned agrees to hold The March and Shomrei (as well as any other organizations participating in any activities relating to The March) and the leadership of these organizations, harmless from any claim, loss, damage, injury, liability or expense (including attorney’s fees) which the undersigned might sustain or incur in connection with, as a result of, or by reason of their participation in The March or any of the activities relating thereto. The organizations sponsoring The March operate the tour offered under this program only as agents of the airline, bus operators and others which provide the actual arrangements, and are not liable for any act, omission, delay, injury, loss, damage, or nonperformance occurring in connection with these arrangements.

4. The undersigned also understands that he/she is expected to participate in all orientation and pre-March courses that will take place in his/her community.

5. Please note that while all food provided by The March is Kosher, we cannot provide for special dietary needs.

By placing my name below, I acknowledge, confirm, accept and agree to be bound by the above agreement and understanding: *
Your answer
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