March of the Living South Africa
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Home
About
March of the Living
The Team
Adult Delegation
Programme Info
Young Adult
Visa & Travel Info
Apply
Gallery
Youth Delegation
Programme Info
Visa & Travel Info
Apply
Testimonials
Blog
Gallery
March of the Living Adult Delegations 2020
Application Form
Please complete the application form below.
Note: partial forms cannot be saved
.
1. Applicant Information
*
Indicates required field
Full Name (As Shown on Passport)
*
Home - Physical Address
*
Home - Postal Address
*
Occupation
*
Work - Physical Address
*
Work - Postal Address
*
Phone Number (Home)
*
Phone Number (Cell)
*
Phone Number (Work)
*
Email (Important - all communications will be sent here!)
*
Additional Email (Optional)
*
Which programme are you applying for:
*
YOUNG ADULT: Poland
ADULT: Poland
ADULT: Poland & Israel
2. Passport Information
Citizenship(s)
*
Date of Birth (DD/MM/YY)
*
Gender
*
Female
Male
Passport Number
*
Country
*
Expiry Date (DD/MM/YY)
*
3. Emergency Contact
Name
*
Phone Number
*
Relationship to Applicant
*
4. Health History
Are you generally in good health? (If no, please elaborate)
*
Are you taking any medication?
*
Do you suffer from any allergies?
*
Describe any physical handicaps, restrictions or disabilities you may have
*
Have you ever been in any kind of therapy (physical, psychological, social or other) ?
If so, please indicate below. All information will be kept strictly confidential.
Name of person consulted
*
Profession
*
Dates of Consultation
*
Reason for therapy
*
Have you suffered a significant loss? Please describe.
*
5. Personal Profile
Are any of your family survivors of the Holocaust? If yes, please list:
*
Did any of your relatives perish in the Holocaust? If yes, please list:
*
Why do you want to participate on the March of the Living? (please provide as detailed a response as possible):
*
Submit