INSTRUCTIONS TO THE APPLICANT

(Please read carefully before completing.Type or print legibly in pen.)

1. Answer all questions on this Application Form. Please type or print clearly. Answer all questions fully. If
you wish to give additional information, attach an extra sheet.
2. Be sure to attach six (6) passport type photos of yourself.

March of the Living

New England Region
REGIONAL DIRECTOR
Richard S. Walter
OFFICE
360 Amity Rd
Woobridge, CT 06525
PHONE
203.387.2522 x300

3. The medical form must be completed by you and your physician. The form must be signed by the
physician.
4. If you are applying to be a staff person, it is imperative that you schedule a meeting/interview with the
regional director.

I am applying to be staff :

Yes

No

I am a Holocaust Survivor:

Yes

No

I am a member of the clergy:

Yes

No Ordination ................................................................................

FAX
203.387.1818
EMAIL
rwalter@jewishnewhaven.org

SCHEDULE OF FEES

WEB

Trip Fee:

www.molnewengland.com

Student:



Survivor:



Clergy/Staff:


Adult Participant:

Application Fee:

All Participants

$4,600
$4,400
$4,400
$4,800 ($3,300, Poland only)

$50 (in addition to trip fee)

Cancellation Insurance:

All Participants

$100 (in addition to trip fee)

Payment Schedule

Paperwork Due

No later than: November 30, 2011-all participants

$50.00 application fee (non-refundable)

$100.00 cancellation insurance
$500.00 deposit
$650.00

Completed application due

$2,050.00 50% of trip fee balance (student)

$1,950.00 50% of trip fee balance (survivor)
$1,950.00 50% of trip fee balance (staff)
$2,150.00 50% of trip fee balance (adult)

Completed Recommendation due

No later than: February 1, 2012

No later than: December 31, 2011

$2,050.00

$1,950.00

$1,950.00

$2,150.00

50 % of trip fee balance (student)

50% of trip fee balance (survivor)
50% of trip fee balance (staff)
50% of trip fee balance (adult)

Completed Medical forms due

PLEASE MAKE ALL CHECKS PAYABLE TO: JCCNH

CJLL/JCCGNH will accept Visa, MasterCard, or American Express with a
3% convenience charge
No participant will be ticketed on flights without full payment of the balance due.
Please see International March of the Living Cancellation Policy.

Name of Applicant: ................................................................................................................................

Please attach 6 passport type

photos of yourself

Email ..........................................................................................................................................................

PERSONAL DATA
Name as Appears on Passport:
.................................................................................................................................................................................................................................................................................
Last











First













Middle

Home Address:.....................................................................................................................................................................................................................................................
Home Phone .................................................................................. Cell ......................................................................... Business ..............................................................
Date of Birth ................................

Age .........

Sex: Male Female

Name you prefer to be called..........................................................................

Health Insurance Coverage:

Company.........................................................................................................Policy # ................................................................................
Country of Citizenship ......................................... Country of Residence ..............................
Passport you travel with: Country................................................Passport # .......................................................................................Exp Date.....................................
Citizen of Israel: Yes

No Israeli Passport # .................................................. Exp Date:..................................Pator?..........................................................

Emergency contacts, in the United States:

Name............................................................................................................ Relationship to applicant ..............................................
Home Phone .................................................................................. Cell ......................................................................... Business ..............................................................
Name............................................................................................................ Relationship to applicant ..............................................
Home Phone .................................................................................. Cell ......................................................................... Business ..............................................................
PERSONAL INFORMATION
What are your special interests, hobbies, or talents? Please check areas of talent or interest

Singing

Playing a musical instrument

Writing/Creative Writing
Photography

Art

Acting

Videography

Public Speaking"

Computer Techie
Other

Would you bring a musical instrument with you on the March?

Yes
No
What instrument?...........................................................................

What type of religious service do you ordinarily attend?

Orthodox

Conservative
Reform

Reconstructionist

Other ................

None

Synagogue Affiliation

Yes
No
Name of
Synagogue .......................................................................................................................................................
Would you be willing to help lead songs, prayers, or religious services?

Yes
No

Please specify .......................................................................................................................................................................................................................................................

Have you suffered a significant recent loss? Please describe
.................................................................................................................................................................................................................................................................................
Are any of your family members survivors of the Holocaust?
.................................................................................................................................................................................................................................................................................

Did you lose any relatives in the Holocaust?

........................................................................................................................................................................................................................................................................................
Employment History:
Company

Dates Employed

Position

.................................................................................................

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................................................................................

.................................................................................................

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.................................................................................................

......................................................

................................................................................

Dates Attended

Degree

.................................................................................................

......................................................

................................................................................

.................................................................................................

......................................................

................................................................................

.................................................................................................

......................................................

................................................................................

Post High School Education - list all schools attended:

School Name

Jewish Education - list all Jewish schools attended - including day schools and supplementary schools:
School Name

Grades Attended

Dates Attended

.................................................................................................

......................................................

................................................................................

.................................................................................................

......................................................

................................................................................

.................................................................................................

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Jewish Organizational Affiliation (please indicate any leadership position held)

......................................................

......................................................

......................................................

......................................................

......................................................

......................................................

......................................................

......................................................

Have you ever been to Poland before?

Yes

No

Date(s).............................................................................

Have you ever been to Israel before?

Yes

No

Date(s).............................................................................

APPLICANTS STATEMENT
The undersigned intends to participate in the March of The Living (The March). In connection with his or her participation, the undersigned hereby
agrees to abide by the rules and regulations of the March.
The undersigned is providing medical information to the leadership of the March 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.
The undersigned agrees to hold the March of The Living, Inc. (March), The Center for Jewish Life & Learning of the JCC of Greater New Haven (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 attorneys 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 non- performance occurring in connection with these arrangements.
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.

Applicants Signature .............................................................................................................................................

Date........................................................