IAC Young Leadership Mission to March of the Living Application 2020
Dear Applicant,

Shalom and thank you for your interest in the IAC Young Leadership March of the Living Mission.

Together we will embark on a life-changing journey and gain deep knowledge of the Holocaust. We will bring home a richer, deeper understanding of the past and translate this experience into action – to build a stronger Israeli-Jewish-American Identity and community, and a stronger bond between Israel and the US.

The program will officially begin on Tuesday, April 20, 2020 at 8 a.m. in Krakow, Poland and conclude Saturday evening, April 25, 2020 in Warsaw after Havdalah.

As you fill out the following application, please be assured that all information will be protected by The International March of the Living and Israeli-American Council.

Please note that an application must be completed by each individual and will need to be completed in one session. A full payment will be due by December 1, 2019.

Refund/Cancellation: Deposit of $500 is due by November 1st. Payments are due in full by December 1, 2019. If cancellation occurs between December 2, 2019 and January 15, 2020 an administration fee of $700 per person will be assessed. If cancellation is between January 16, 2020 and February 15, 2020, an administration fee of $900 will be assessed. If cancellation occurs between February 16, 2020 and March 14, 2020 an administration fee of $1100 will be assessed. There are no refunds after March 15, 2020.

Prior to beginning the application, please have your health insurance card, emergency contact information, passport number and expiration date available (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 two items:
1. Payment of $2150 made out to "Israeli-American Council". Write the name of the applicant and MOTL on the bottom of the check. All fees are based on double occupancy. There is a supplement charge for single occupancy (the supplement for single occupancy is $550). Payments by credit card will incur a fee of 3% and can be submitted here: https://www.tfaforms.com/4704522
2. Please email a copy of your passport to dustin@israeliamerican.org 

Checks to be mailed to:
Israeli American Council
Attention: Dustin Bitton
5900 Canoga Ave. Suite 390
Woodland Hills, CA 91367

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.

If you have any questions, please contact Dustin Biton at dustin@israeliamerican.org or Monise Neumann, National Consultant, International March of the Living at monise@motlmail.org
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Email *
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 *
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Address *
City *
State *
Zip Code *
Country of Residence *
Cell Phone *
Home Phone
Marital Status *
Spouse/Partner Name (If Applicable)
With which denomination of Judaism do you most identify?
Are you a member of IAC? *
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:
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:
Have you been to Poland before? *
What languages do you speak? *
Required
PROGRAM & FLIGHT INFORMATION
The Israeli American Council (IAC) Young Leadership Mission to March of the Living Delegation full program is 5 days and 6 nights in Poland. The cost of the program includes land only while in Poland. Flights from the USA to Poland and back to the USA 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% and can be submitted here: https://www.tfaforms.com/4704522
Program applying for *
Required
Additional Services
Clear selection
Roommate Preference Poland *
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
Secondary Country of Citizenship (if applicable)
Name as it appears on your Secondary Passport (if applicable)
Secondary Passport Number (if applicable)
Expiration Date of Secondary Passport (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 Israeli American Council ("IAC"). 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 IAC  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 IAC (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: *
A copy of your responses will be emailed to the address you provided.
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