2010 MOTL - Part A

Welcome to the on-line application for the BJE March of the Living-LA. This form has two parts:

PART A (below) - the On-line form has one section.

PART B- the Personal Data Form must be downloaded (available on completion of part A). This form must be filled out and mailed to the BJE March of the Living-LA office with a deposit check and three 2"x2" headshot photos by December 11, 2009. Our address is BJE March of the Living, 6505 Wilshire Boulevard, Suite 300, Los Angeles, CA 90048.

Please complete this application fully. ANSWER ANY OBLIGATORY QUESTION THAT DOES NOT APPLY TO YOU BY WRITING "NONE" OR "N/A."

FOR THIS APPLICATION TO BE SUBMITTED, YOU MUST CLICK THE "SUBMIT" BUTTON AT THE BOTTOM OF THE PAGE.

Please be sure that you capitalize properly in your basic information (name, address, etc.)

Applicant's Name (as it appears on the passport) *

First Name *

Middle Name

Last Name *

Name you prefer to be called *

Date of Birth *

Applicant's Address

Street *

City *

State *

Zip *

Applicant's Contact Information: *

Home Phone # *

Email *

Cell Phone #

Parents' Contact Information

Mother's Name *

Mother's Email *

Mother's cell # *

Mother's work #

Father's Name *

Father's Email *

Father's cell # *

Father's work #

Mother's/Father's address if different from applicant's home

Guardian's Name

Guardian's Home Phone

Guardian's Address

Guardian's Work Phone

Guardian's Cell Phone

Applicant's Nationality

Country of Residence *

Country of Citizenship *

Passport # *

Passport expiration date *

Did your parents ever hold Israeli citizenship? * yesno

Are you a citizen of Israel? * yesno

If yes, Israeli Passport #

Israeli Passport expiration date

Additional Information

Applicant reflection: Please write briefly about why you want to participate in the March of the Living *

Emergency Contacts in case parent or guardian can not be reached.

Name of Emergency Contact #1 *

Relationship to Applicant *

Home Phone Number *

Cellphone Number *

Name of Emergency Contact #2 *

Relationship to Applicant *

Home Phone Number *

Cellphone Number *

Educational Data

Name of Current High School *

Grade as of September 1, 2009 *

Request for Financial Assistance

Please send me information on applying for financial assistance. yesno

Jewish Involvement

Jewish youth programs or organizational involvement (indicate current and past involvement) *

Summer Camp and/or travel experience (nature of the program and dates attended) Please include both Jewish and secular experiences in this section. *

Israel program experience (Please described the program you attended and dates attended) *

Israel: family or independent travel (dates and nature of the trip) *

Have you ever been to Poland before? yesno

If yes, please describe the program or trip that included a visit to Poland.

Other Jewish involvement

Please note: Be aware that while all food on the March of the Living is kosher and vegetarian options are available, we cannot accommodate other special dietary needs.

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