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March of the LivingNew England Region
REGIONAL DIRECTOR
Richard S. Walter
OFFICE
360 Amity RdWoobridge, CT 06525
PHONE
203.387.2522 x300
FAX
203.387.1818
EMAIL
rwalter@jewishnewhaven.org
WEB
www.molnewengland.com
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.
3. The medical form must be completed by you and your physician. The form must be signed by thephysician.4.If you are applying to be a staff person, it is imperative that you schedule a meeting/interview with theregional 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 ................................................................................
SCHEDULE OF FEES
Trip Fee:Student:
$4,600Survivor:
$4,400Clergy/Staff:
$4,400Adult Participant:
$4,800 ($3,300, Poland only)Application Fee:
All Participants
$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)
Completed application due$100.00 cancellation insurance$500.00 deposit$650.00
No later than: December 31, 2011
$2,050.00 50% of trip fee balance (student)
Completed Recommendation due$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)
No later than: February 1, 2012
$2,050.00
50 % of trip fee balance (student)
Completed Medical forms due$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)
 
PLEASE MAKE ALL CHECKS PAYABLE TO:
 JCCNH
CJLL/JCCGNH will accept Visa, MasterCard, or American Express with a3% 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: ................................................................................................................................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
Art
Acting

Videography
Public Speaking
"
Writing/Creative Writing
Photography
Computer “Techie”
OtherWould 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 ................
NoneSynagogue Affiliation
Yes
No
Name of Synagogue .......................................................................................................................................................Would you be willing to help lead songs, prayers, or religious services?
 
Yes
NoPlease specify .......................................................................................................................................................................................................................................................Have you suffered a significant recent loss? Please describe.................................................................................................................................................................................................................................................................................Are any of your family members survivors of the Holocaust?.................................................................................................................................................................................................................................................................................Please attach 6 passport typephotos of yourself 
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