Contact Us

Phone
US: 312-267-0677
Israel:+972-2-633-1144

Fax
US: 312-276-4739
Israel:+972-2-533-0552

Email Addresses:
General:
info@shorashim.org
Taglit-Birthright Israel:
birthrightisrael@shorashim.org
H.S. Programs:
israeladventure@shorashim.org
Club Israel:
info@clubisrael.org

Websites:
www.shorashim.org
www.israelwithisraelis.com
www.clubisrael.org

Israel Adventure Registration

Please fill out the application below completely and accurately.

Applications will be reviewed after submission of the $250 deposit fee (fully refundable until May 1, 2012) and will be accepted after a brief interview.

If you have any questions about the application, please contact Kira Moscowitz - kira@shorashim.org or 312-267-0677.

Contact Information

Please provide the following information for the person filling out this form - who will be considered the main contact person for this registration (typically a parent). You may indicate below your permission for Shorashim to contact either parent to discuss registration.

First Name: *

Last Name: *

Email: *

This email address will be used for all registration and billing information

My relationship to the participant:

Shorashim may contact EITHER parent below regarding registration

Participant Details

First Name: *

Middle Name:

Last Name: *

Email: *

Mobile Phone:

Format: XXX-XXX-XXXX

Birthdate: *

Month: *

Day: *

Year: *

Gender: *

High School: *

Current Grade:

Synagogue:

Trip Details

I would like the following Euro Plus option:

Passport Expiration Date: *

Month: *

Day: *

Year: *

I may be interested in extending my trip or flying separately from the group

I may be interested in traveling with friends (please list names here, even if they are not yet registered):

Participant T-Shirt size: *

Family Contact Information

Address (Line 1): *

Address (Line 2):

City: *

State: *

ZIP: *

Phone:

Format: XXX-XXX-XXXX

Mother First Name: *

Mother Last Name: *

Mother Mobile Phone:

Format: XXX-XXX-XXXX

Father First Name: *

Father Last Name: *

Father Mobile Phone:

Format: XXX-XXX-XXXX

Participant resides with: *