EmailMe Form - Registration Form | Dr. Andres J. Peralta

Title

I will be returning on: *

July 31, 2018 from Berlin

August 5, 2018 from Frankfurt

Last Name *

First Name *

Middle Name

Gender *

Male

Female

Passport Number *

Date of Issue *

MM / DD / YYYY

Date of Expiration *

MM / DD / YYYY

Country of Citizenship *

Date of Birth *

MM / DD / YYYY

Travel Insurance (booked directly with the Atlantic Union Youth Department)

Yes

No

Meal Request on Flight

Regular

Vegetarian

Kosher

Additional Family Member Traveling with you:

Last Name

First Name

Middle Name

Gender

Male

Female

Passport Number

Date of Issue

MM / DD / YYYY

Date of Expiration

MM / DD / YYYY

Country of Citizenship

Date of Birth

MM / DD / YYYY

Travel Insurance (booked directly with the Atlantic Union Youth Department)

Yes

No

Meal Request on Flight

Regular

Vegetarian

Kosher

Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please make sure to include your apartment number to guarantee delivery of travel documents.

Phone *

### - ### - ####

Email *

Room Type *

Single Room (for 1 person only = +$495)

Double Room (for 2 people only = 1 double bed)

Twin Room (for 2 people only = 2 twin beds)

Triple Room (for 3 people only = 2 twin beds + sofa bed/cot)

If you chose a Double, Twin, or Triple room, please list your roommate(s) name(s) below:

Questions or Comments:

Please Note:

1. Current airport taxes are subject to change by the airline prior to ticketing
2. Price is based on a minimum of 25 participants
3. Please submit a copy of your passport, which must be valid for at least 6 months from the date of departure
4. To complete your registration, a deposit of $250 per person is required

Mailing address for $250 deposit + passport copy:

Go Israel NA
200 Winston Drive #1702
Cliffside Park, NJ 07010

5. To pay your deposit by credit card, please visit our secure website:

www.GoIsraelNA.com/payment.htm

* Please note: for international credit cards there is a 4.5% processing fee

6. By signing this form you agree to our Terms & Conditions:

www.GoIsraelNA.com/terms.htm

Signature: *

Today's Date *

MM / DD / YYYY