YIHםעם

Operation Chizuk and Chesed Application

"*" indicates required fields

Name*
(as you would like to be called on the trip)
Gender*
Date of Birth*
Name*
(as appears on passport)
Passport information
Your passport needs to be valid for at least 6 months AFTER your return date. If you are waiting for your passport you may write "pending", and enter today's date for the expiration date. Please email your passport information to admin@israeldestination.co.il as soon as you have it.
0 of 10 max characters
Exp. Date*

Contact Information

Address*

Special Requirements

Do you have any accessibility requirements or physical limitations or restrictions?*
Do you have any special dietary requirements or allergies?*
Are you currently taking any medication?

Other

Will you be accompanied by anyone?

Waiver

Participant Waiver*

For any further question please contact us at: eitan@israeldestination.co.il