Temple Beth Sholom March of the Living Application 2020
Dear Applicant,

Shalom and thank you for your interest in the 2020 Temple Beth Sholom March of the Living.

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

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 $1000 deposit. The deposit is fully refundable if cancelled prior to November 24, 2019.  After November 25th the deposit is not refundable. In December, you will be sent a statement for your travel costs and payments are due in full by December 15, 2019.

​Refund/Cancellation: ​Payments are due in full by December 15, 2019. If cancellation occurs between December 16, 2019 and January 1, 2020 an administration fee of $1500 per person will be assessed. If cancellation is between January 2, 2020 and February 1, 2020, an administration fee of $2500 will be assessed. If cancellation is between February 1, 2020 and March 14, 2020 an administration fee of $3500 will be assessed. There are no refunds after March 15, 2020.

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 $1000 made out to "Temple Beth Sholom". Write the name of the applicant and MOTL on the bottom of the check. No application will be considered without a deposit. Payments by credit card will incur a fee of 3%
2. Copy of the front page of your passport that shows all of your identification information and your photo.

Mail these items to:
Temple Beth Sholom
Attention: Nicole
10700 Havenwood Lane
Las Vegas, NY 89135

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: Contact Rabbi Felipe Goodman at rabbi@bethsholomlv.org
Sign in to Google to save your progress. Learn more
PERSONAL INFORMATION
Last name (as it appears on your passport) *
First name (as it appears on your passport) *
Middle name (as it appears on your passport) *
Hebrew Name
Date of Birth *
MM
/
DD
/
YYYY
Address *
City *
State *
Zip Code *
Country of Residence *
Cell Phone *
Home Phone
Marital Status *
Spouse/Partner Name (If Applicable) *
Have you been to Poland before? *
Have you been to Israel before? *
What languages do you speak? *
Required
PROGRAM & FLIGHT INFORMATION
The Temple Beth Sholom March of the Living Delegation full program is one week in Poland and three days in Israel. The cost of the program includes land only while in Poland and Israel, as well as the flight from Poland to Israel. Please note  the price includes accommodation for the night of Sunday, April 19th at the hotel in Krakow prior to the official start of the program on Monday, April 20th. Flights from the USA to Poland and back to the USA from Israel are the responsibility of each individual participant.

All fees are based on double occupancy, with a minimum of 35 participants. Payments by credit card will incur a fee of 3%
Program applying for *
Required
Additional Services - Pricing Info not yet available but will be soon. *
Are you interested in extending your stay in Israel? *
Roommate Preference Poland *
Roommate Preference Israel *
For Double Occupancy *
Name of Preferred Roommate (if applicable)
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 29, 2020. 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 *
Name as it appears on your Primary Passport *
Primary Passport Number *
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)
Israeli Passport Expiration Date (If Applicable)
MM
/
DD
/
YYYY
Secondary Country of Citizenship, other than Israel (if applicable)
Name as it appears on your Secondary Passport, other than Israel (if applicable)
Secondary Passport Number, other than Israel (if applicable)
Expiration Date of Secondary Passport, other than Israel (if applicable)
MM
/
DD
/
YYYY
HEALTH INSURANCE
Health Insurance Company Name *
ID Number *
Group Number (If Applicable)
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 *
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:
List any allergies. Include drug, food and environmental, including insects. If none, please indicate so *
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 *
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:
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. *
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:
EMERGENCY CONTACTS
Primary Emergency Contact Full Name (Cannot be someone traveling on the trip with you) *
Primary Emergency Contact Relationship *
Primary Emergency Contact Cell Number *
Primary Emergency Contact Home Phone *
Primary Emergency Contact Email *
Secondary Emergency Contact Full Name (Cannot be someone traveling on the trip with you) *
Secondary Emergency Contact Relationship *
Secondary Emergency Contact Cell Number *
Secondary Emergency Contact Home Phone *
Secondary Emergency Contact Email *
APPLICANT AGREEMENT & UNDERSTANDING
1. The undersigned intends to participate in the March of The Living (“The March”) with Temple Beth Sholom ("TBS"). 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 TBS 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 TBS (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: *
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
This form was created inside of International March of the Living.