THE J² REGISTRATION FORM.
PLEASE COMPLETE THIS FORM FOR EACH TRAVELER. A J²REPRESENTATIVE WILL BE IN TOUCH TO SHARE MORE INFORMATION AND COLLECT MORE DETAILS CLOSER TO THE TRAVEL DATE.

In addition to this price, all participants are expected to make a $1,000 per person donation directly to Congregation Or Ami. Questions? Please contact Rabbi Kipnes directly.

TRIP NAME

Congregation Or Ami | Family Trip to Israel | Led by Rabbi Paul Kipnes | June 2023

CONTACT DETAILS

SURNAME

FIRST NAME

MIDDLE

PRONOUNS

(Optional) What are your pronouns? (e.g. she/her, he/him, they/them, use my name) For information

about pronouns, please see: https://urj.org/quick-guide-pronouns

ARE YOU A SINGLE TRAVELER?

IF YOU ARE NOT A SINGLE TRAVELER PLEASE ADD THE NAME OF YOUR ROOMMATE

IF YOU WOULD LIKE A ROOMMATE BUT DO NOT YET KNOW WHO THAT WILL BE, PLEASE INDICATE "TBA" IN PLACE OF THE NAME.

DO YOU HAVE ANY DIETARY RESTRICTIONS OR ALLERGIES ?

EMERGENCY CONTACT NOT TRAVELING ( NAME AND PHONE NUMBER)

PASSPORT INFORMATION

DATE OF BIRTH.

PASSPORT NUMBER

EXPIRATION DATE.

CITIZENSHIP

FULL CONTACT INFORMATION

FULL HOME ADDRESS (STREET, CITY, STATE, COUNTRY)

EMAIL

MOBILE

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