LLE Application & Registration Form

Application Form

Please fill out all the required fields of the form (one application per person)
Select Group
Select Trip Date
Event Start Date

MonthDayYear
Date
Event End Date

MonthDayYear
Date
Personal Information
First Name
Last Name
** PLEASE ENTER A UNIQUE LAST NAME **
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
Please use a unique email address for every applicant
Gender
Date of Birth

MonthDayYear
Date
Street Address
Street Address Line 2
Zip/Postal Code
Marital Status
Do you require a single room? (Single room supplement is $600 USD)
Who would you like to room with?
What is your relationship to the requested roommate?
Who else are you traveling with?
Is this your first time traveling to Poland on an organized trip?
Priority will be given to those traveling for the first time
Passport Information
Name as it appears on passport?
Passport Expiry Date

MonthDayYear
Date
How do you want your name spelled on your name badge?

First NameLast Name
Address

Street Address

Street Address Line 2

CityState/Province

Zip/Postal CodeCountry
Jewish Background
Jewish Education
Current Jewish Affiliation
Are you a member of a synagogue?
If yes, which Synagogue?
Is your Mother Jewish?
Is your Father Jewish?
If you were not born Jewish, did you convert?
Special Requirements
Are you currently taking any medications?
If yes, please elaborate
Do you have any special dietary requirements?
If yes, please elaborate
Do you have any accessibility restrictions?
If yes, please elaborate
Emergency Contact

(must be someone NOT traveling with you)
Emergency Contact Name

First NameLast Name
Relationship to Applicant
Phone Number of Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of Emergency Contact
example@example.com
How did you hear about us?
Please Specify
Pricing
Age: 20 - 39 - $995 USD + Flight (Including Deposit)

Age: 40+ - $1,895 USD + Flight (Including Deposit)

The true land cost of the trip is $2,195 USD (Including Deposit) per participant.

The trip is being generously subsidized by individuals and organizations who deeply connect with The Living Legacy Experience and its mission.
Would you be able to cover the full cost of the trip?
By clicking NEXT, you will be directed to pay the $399 USD deposit.

Your application is not complete until the deposit has been paid.

Someone will be in touch with you up to 7 days after completing your application.

NOTE: DO NOT BOOK YOUR FLIGHT UNTIL YOU HAVE WRITTEN CONFIRMATION FROM US

The Living Legacy Experience

Living Legacy Applicant Deposit

$399.00

Enter coupon

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

Application Form

Personal Information

Passport Information

Jewish Background

Special Requirements

Emergency Contact

Pricing

The Living Legacy Experience*

The Living Legacy Experience