Jewish Federation of Greater Atlanta From Surviving to Thriving April 12-26, 2015

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1 Jewish Federation of Greater Atlanta From Surviving to Thriving April 12-26, 2015 Please complete this application in full and submit it to Meredith Lefkoff at How much do you know about our Jewish history? What have you learned about the lives that were lived and lost during the Holocaust? Do you know about the Jewish renewal that s taking place around Eastern Europe? Pack your bags and join us for the experience of a lifetime. For the first time ever, the Jewish Federation of Greater Atlanta is offering a multi-generational trip to Poland and Israel as part of the March of the Living experience. Only 30 spots are available so pay your deposit and register now! Program: Locations: Atlanta s From Surviving to Thriving Experience Poland and Israel Dates: Departing Atlanta Sunday, April 12 and returning Sunday, April 26, 2015 Price: Deposit: $6,800; inclusive of airfare, hotels, meals, land fees, and gratuities (Subsidies are available for those between the ages of 16 and 35) $500 (refundable prior to December 1, 2014 only) Application: Must be completed and submitted with deposit Contact: Meredith Lefkoff at mlefkoff@jfga.org or Along with this application, you must: 1. Submit a $500 deposit. Additional fees and deadlines are included later in this application. 2. a copy of the front and back of your health insurance card. 3. a copy of the first page of your Passport. Education Classes: To prepare for the 2015 March of the Living, you will be required to attend 4 pretrip education classes and 1 post-trip debrief. In these classes, you will examine Jewish history through the lens of the choices that the Jewish people had at different points in their history and look critically at how certain events in history shaped Jewish attitudes, viewpoints and decision making. The preparation course will be highly interactive, focused on classroom discussion, and include the use of primary source documents and testimonies. 1 / 5

2 Application & Release Forms Please print legibly and sign where indicated Status: Teen Young Adult (under 35) Adult Personal Information Title Full name exactly as appears on passport (Last, First, Middle) Name as you'd like it on name tag Male Female Date of birth MM / DD / YYYY Passport # Passport expiration date* MM / DD / YYYY Country of issue: Country of citizenship: Are you an Israeli Citizen? Yes No Frequent Flyer # and Airline Flights will depart from and return to Atlanta. Fees include roundtrip coach airfares. Would you like to reserve business-class seats for an additional fee? Yes No * Note: Passports must be valid for at least six months beyond the return date of the trip. Street Apt./Suite # City State Zip Code Home phone ( ) Work ( ) Cell ( ) Other Information Dietary Restrictions Kosher * Vegetarian Other (please specify): *Note that all March of the Living meals are Kosher style. Kosher meals will be made available upon request. T-Shirt Size Small Medium Large X-Large XX-Large (Men s sizes) Jacket Size Small Medium Large X-Large XX-Large (Men s sizes) Are you or any of your immediate family members survivors of the Holocaust? If so, please list names and relationships. Did you lose any close family relatives in the Holocaust? If so, please list names and relationships. 2 / 5

3 Have you previously been to Poland, Minsk, or Israel? If so, please describe the nature of your experience. Briefly explain why you want to participate on the March of the Living. Do you speak any other languages, such as Hebrew, Yiddish, Polish, or Russian? With which denomination of Judaism do you most identify? Reform Conservative Orthodox Reconstructionist Other Do you belong to a synagogue in Atlanta? If so, which one? Room Assignments Room Type - Please check applicable box. (Trip fees are based on double-occupancy.) Room Type Double Room Single Room Indicate roommate request if applicable. Additional $1,500 per person. Note Medical & Emergency Information Health Insurance Company: Policy Number: Name of Primary Policy Holder: Allergies: Prescriptions: Medical conditions: Emergency contact (someone not traveling with you): Name Relationship Address City State Zip Home phone ( ) Work ( ) Cell ( ) 3 / 5

4 Charges to your credit card will be made as follows: Billing/Payment Application -- $500: Per person deposit upon receipt of application; fully refundable before December 1, 2014 December 15, %: Half the cost of the March (less the $500 deposit) February 1, 2015 Final Balance: Remaining cost of the March If you prefer to not charge by credit card, you may send checks, payable to Jewish Federation of Greater Atlanta, for your deposit and other payments by the deadlines listed above. Please mail all checks to Jewish Federation of Greater Atlanta, Attn: Meredith Lefkoff, 1440 Spring Street NW, Atlanta, GA Credit Card Information Please check one: Visa Master Card Amex Discover Card Number Expiration Date Credit Card Validation/Security Code # (CVV): This is the 3-digit security code used to verify your credit card and protect you against fraud. The code is 3 digits long and is located on the back of the card. Note that for American Express cards, the code is 4 digits on the front of the card. Cardholder's Name: Cardholder's Signature: I hereby authorize The Jewish Federation of Greater Atlanta to charge the credit card provided above. I understand that these payments are necessary in order to reserve airline seats and hotel accommodations. I further recognize that these payments are payments for services (i.e., airfare, hotels, etc.) and not charitable contributions. Signature of Participant Print Name Applicant Signature Each From Surviving to Thriving participant will face a new and strenuous environment, which will be physically and emotionally stressful. You will be expected to participate in activities which will include long bus rides, walking long distances, and other strenuous activities. You will visit places such as Auschwitz, Majdanek, and Treblinka, where you will be emotionally affected. Please bear in mind that the medical facilities available for participants will cover only acute illness and accidents. There are no facilities available within the framework of the trip for the treatment of chronic disturbances. As such, we strongly recommend that you have a complete physical with your doctor before the trip to ensure that you are physically and emotionally prepared for this trip. By signing below, you assert that you understand the expectations of participating in the trip and agree that everything you have written in this application is honest and correct. The undersigned also understands that he/she is expected to participate in all pre-trip orientation sessions (up to 4) that will be held in Atlanta. Name Signature Date 4 / 5

5 Mission Name: Atlanta s From Survivng to Thricing Dates: April 12-26, 2015 Photo/Image Release I hereby grant the permission, without reservation, to the Jewish Federation of Greater Atlanta ( JFGA ) to take and to use photographs and/or sound/image recordings of me, to describe and to use the same for promotion of good will, public education, and/or fundraising and other related activities of Federation, and I waive any right to inspect or approve the photograph(s) or finished version(s) of works, including web site, incorporating the photograph(s). I release JFGA, its officers, trustees, agents, employees, independent contractors, licensees and assignees (including photographers), from all claims that I may have or might have, for any cause of action arising out of taking and/or use of the photographs and/or any sound/image recordings, and/or description of the same, be it blurring, distortion, alteration, optical illusion, or use of composite form whether intentional or otherwise, that may occur or be produced in taking of photographs, or any processing toward the completion of the finished product, unless it can be shown that they and the publication thereof were maliciously caused, produced and published solely for the purpose of subjecting me to conspicuous ridicule, scandal, reproach, scorn and indignity. I recognize that JFGA owns the copyright (or may apply for copyright) in these photographs and other works and creations, and I hereby waive any claims I may have based on any usage of the photographs or works derived there from in any form, whether it be printed, projected, televised or transmitted via the web, or/and at any time, be it in the present or in the future, including, but not limited to claims for either invasions of privacy or libel. I am of full age and competent to sign this release. I agree that this release shall be binding on legal representatives, my heirs, assigns, and me. I have read this release and I fully understand its contents. Name Signature Date Complete address Telephone ( ) 5 / 5

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