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Apply for Israel Bound

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Participant Information
Name as it appears or will appear on passport*
First Middle Last
Nickname (if applicable)
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Participant Email*
Parents will be CC’d on all emails to participants.
Participant Cell Phone*
Passport Country
Passport Number
Passport Expiration Date
NOTE: Passport must be valid for 6 months past the scheduled return date – January 4, 2023.
Date Format: MM slash DD slash YYYY
Passport Pending
- Yes
- No
Current Grade*
High School*
Synagogue Affiliation (if applicable)
T-Shirt Size*
- Small
- Medium
- Large
- XL
- XXL
Passport to Israel Participant?*
- Yes
- No
Has the participant previously been to Israel?*
- Yes
- No

Parent/Guardian Information
Parent/Guardian 1 Name*
First Last
Parent/Guardian 1 Email*
Parent/Guardian 1 Home Phone
Parent/Guardian 1 Cell Phone*
Parent/Guardian 1 Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian 2 Name
First Last
Parent/Guardian 2 Email
Parent/Guardian 2 Home Phone
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Address
Same as Parent/Guardian 1

Street Address Address Line 2 City State ZIP Code
Parent/Guardian Relationship Status*
- Married
- Divorced
- Separated
- Widow(er)
- Single
Who does the participant live with?*
- Both Parents/Guardians
- Mother
- Father
Who should email communications go to?*
- Both Parents/Guardians
- Parent/Guardian 1
- Parent/Guardian 2
Decision Making Authority: Please indicate which parent is responsible financially for program tuition as well as which parent is legally authorized to make decisions and provide consent on behalf of the participant as pertaining to the Israel Bound trip.*

Emergency Contact Information
Emergency Contact Name*
This should not be a parent or guardian.
First Last
Relationship to Applicant*
Email*
Cell Phone*
Home Phone

Payment Information
Trip Dates and Pricing
- Trip Dates: June 13-July 4, 2022
- Trip Price: $6,050 All Inclusive (includes round-trip flight from St. Louis)
- Note: $3,000 Root One Voucher Available – Price reduced to $3,050
- St. Louis teens are eligible for $750 Travel Grant
- Including Root One Voucher and Travel Grant, the out of pocket cost comes to $2,300
Payment Schedule

A $500 fully refundable deposit is due with this application. On March 31, 2022, the remaining balance of the trip is due.

Passport to Israel, Grants, and Scholarships

Passport to Israel funds, grants, and scholarships will be applied prior to the final payment due March 31, 2022.

Refunds

Refunds requested after the final payment will be reviewed on a case-by-case basis by the Jewish Federation of St. Louis.
$500 Deposit Payment Type*
- Check: Make $500 check payable to the Jewish Federation of St. Louis and mail to Jody Gerth at 12 Millstone Campus Drive, St. Louis, MO 63146
- Credit Card
Application Deposit*
Price: $500.00
Billing Address*
Same as Parent/Guardian 1

Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Terms of Acceptance
- The parent or guardian certifies that the applicant is currently healthy and able to participate in all Israel Bound activities.
- The parent or guardian grants permission to use pictures in which the participant appears as part of Israel Bound.
- Jewish Federation of St. Louis reserves the right to adjust the price up to 5% based on exchange rate and airline fuel fee fluctuation. Participants reserve the right to cancel and receive a full refund in the event of a price increase if they so wish.
I have read and will understand the terms as outlined on this registration form.
Parent/Guardian 1 Signature*
Parent/Guardian 2 Signature
Comments
This field is for validation purposes and should be left unchanged.

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