POLAND
Email address *
Full Name (as it appears on passport) *
Your answer
Basic Information
Phone Number *
Your answer
Date of Birth *
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DD
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YYYY
Travel Information
Passport Number *
Your answer
Passport Expiration Date *
MM
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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
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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
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Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
A copy of your responses will be emailed to the address you provided.
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