Jewish Federation of Broward County

This application will take about 20 minutes to complete. As part of the process you will need your passport information and health insurance information. If you do not have a passport or if your passport will expire prior to November 15, 2019, you must apply for one now. It can take months to get a new one and we need this information as quickly as possible.

Upon receipt of this application a personal interview will be scheduled. Please check the website www.orloffcaje.org and click on March of the Living to review the other materials necessary to complete the application package. In addition, you will find the Staff/Adult Calendar of sessions which you should check to be sure you are able to attend all our pre March sessions.

Be reminded, that in addition to the application and medical form, we will need a copy of the inside page (picture page) of your passport, a copy of both sides of your health insurance card and a digital head shot or passport photo, all sent to mol@jewishbroward.org

If you have any questions, feel free to contact Rochelle Baltuch, Director, at 954 660 2077 or rbaltuch@jewishbroward.org

GENERAL INFORMATION

PERSONAL PROFILE

MEDICAL INFORMATION

Note there is a medical questionnaire for your physican to complete. You can find it www.orloffcaje.org Click on March of the Living

It is our intention to rely on the medical information you submit below, along with the physician's form (to be returned separately) and any supplementary letters from specialists or mental health professionals in determining your acceptance and continuation in this program. Omissions or misstatements are at your risk and that of your physician(s) or therapist(s).

Should you be found to have any condition, mental or physical, that is not fully disclosed on this form, the physician's form or in an accompanying letter from an appropriate, qualified medical or mental health professional, you may, at the sole and absolute discretion of the program, be returned to the USA at your own expense, or be treated in the country(ies) you are visiting, at your own expense, and there shall be no refund of monies paid. The leadership of this program and its sponsoring organizations are hereby released from all responsibility or liability of any kind whatsoever arising out of any aspect of your medical history and mental or physical condition.

If any changes take place in your medical or mental condition prior to departure of this program, you must immediately submit a full explanatory letter, signed by an appropriate, qualified medical or psychological professional, detailing your diagnosis, prognosis, and treatment. Failure to submit such a report may result in your expulsion from this program with no refund of fees.

Mark the box(es) next to any medical condition listed below which apply to your health history.

The March of the Living provides 3 kosher meals per day. At the interview we will discuss any dietary requirements listed below

In checking the "Yes" box below, I certify that I am able to participate on the March of the Living, understanding that the trip is strenuous with early wake ups and late curfews, frequent and sometime long bus travel, and many hours of standing and walking. I further agree to immediately send my physician the Medical Form which must be completed and returned to our office PRIOR TO the required interview. This medical form may be found at www.orloffcaje.org Click on March of the Living Staff/Adult Application Center

PAYMENT INFORMATION

I have reviewed this application. All questions have been answered honestly. I have also read the payment and other information below. It is further understood that I will be obligated to conform to the teen Standards of Behavior to be reviewed at the interview as well as agree to attend all sessions prior to and after the March of the Living (a calendar can be found on the website) https://www.orloffcaje.org Click on March of the Living

PAYMENT: Payments by check, money order or MasterCard/Visa are accepted. A form is available on line at the above web address. Checks or money orders may be sent to: March of the Living, 5890 S Pine Island Road, Davie, Fl 33328

Upon acceptance: $500 deposit

Due October 15: 1/2 of balance

Due December 1: Remainder of balance due

A Cancellation policy will be emailed with your acceptance.

APPLICANT AGREEMENT AND UNDERSTANDING

By placing your name below you understand you are providing medical and other information to the providers of the local March of the Living group, International March of the Living and Jewish Federation of Broward County. The undersigned represents that all of the information contained in such forms is true and correct. All medical conditions and medications are true and correct. Omissions or misstatements are at my risk and that of my physician(s) or therapist(s). The undersigned hereby authorizes the leadership of the March of the Living and/or its providers to obtain treatment as it, in its sole and absolute discretion, deems necessary and advisable. The costs of any medical treatment provided shall be the responsibility of the undersigned.

The undersigned agrees to hold the March of the Living, Inc. ("March"), the Jewish Federation of Broward County, as well as any other organization, harmless from any claim, loss, damage, bodily injury, personal injuries, including emotional trauma, known or unknown, death, liability or expense (including attorney's fees) which the undersigned might sustain/alleged sustain or incur/alleged incur in connection with, as a result of, or by reason of their participating in the March or any of the activities relating thereto, whether based upon the negligence or breach of contract by any of the above mentioned organizations/agencies of their representatives.

The organizations sponsoring the March operate the tour offered under this program only as agents of the airline, bus operators, hotel facilities, and others which provide the actual arrangements, and are not liable for any act of omission, delay, injury, loss, damage or nonperformance occurring in connection with these arrangements.

It is further noted by the undersigned that while all food on the March of the Living is kosher, we cannot always provide for all special dietary needs.

Terms and Conditions:

By signing below, I agree to abide by all rules and regulations as set forth by the Broward County March of the Living, International March of the Living or the Jewish Federation of Broward County.

I further acknowledge the information contained in this application is correct and truthful. All information will be used in conjunction with the March of the Living program.

Use your mouse to sign below.