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TEXAS POLAND TRIP
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* Indicates required question
Email
*
Your email
Full Name (as it appears on passport)
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Passport Number
*
Your answer
Passport Expiration Date
*
MM
/
DD
/
YYYY
Covid-19 Vaccination
*
2 or more doses
1 dose
Haven't been vaccinated
Hebrew Name
Your answer
Please briefly describe your Jewish background, including education, and level of observance.
*
Your answer
Please describe your family's Jewish background.
*
Jewish father
Jewish mother
Both parents Jewish
Neither parent Jewish
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
Special dietary needs
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
A copy of your responses will be emailed to the address you provided.
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