POLAND
Basic Information
Full Name *
(as it appears on your passport)
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Travel Information
Passport Number *
Your answer
Passport Expiration Date *
MM
/
DD
/
YYYY
Personal Background
Hebrew Name
Your answer
Please describe your Jewish background, including education and level of observance. *
Your answer
Please describe your family's Jewish background. *
Please provide details of any conversions in family (grandparents, parents). *
Type “none” if not applicable
Your answer
Please use the space below to describe what you hope to offer and gain from the program. *
Your answer
Dietary, Medical, and Other Special Requirements
Do you have any special dietary requirements? *
If yes, please detail below
Your answer
Have you ever taken medications on a protracted basis? *
If yes, please detail below
Your answer
Have you ever been hospitalized? *
If yes, please detail below
Your answer
Do you have any accessibility requirements or physical limitations or restrictions that would affect your participation on the trip? *
If yes, please detail below
Your answer
Is there any other special considerations about you that your trip providers should know?
If yes, please detail below
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms