Applicant Statement and Personal Medical Disclosure Statement
This must be read by STUDENT and PARENT prior to submitting the Application.
MARCH OF THE LIVING DALLAS, April 9th - 23d, 2018
Applicant Statement for Student and Adult Participants
By enrolling in the March of the Living Program, an intensive
Jewish educational experience, I hereby agree to the following:
will participate fully in all its aspects.
I will abide by all its rules and regulations as detailed on the Code of Conduct, above.
I will attend all classes, student retreats and other programs prior to and immediately after the March of the Living.
I acknowledge the fact that usage or involvement in alcoholic beverages, drugs or narcotics or any other type of behavior deemed inappropriate by the staff is cause for my immediate dismissal from the program and my return to the USA at my own or my family"s expense.
I and one of my parents will have read and filled out this application form.
I hereby certify that the Medical Information section is complete and full disclosure of any and all physical and Mental health issues have been included. It is the intention of the March of the Living to rely on this completed form and supplementary letters in determining my acceptance and continuation in this program. Omissions or misstatements are at my risk and that of my physician(s) or therapist(s).
~ Should I be found to have any mental or physical condition that is not fully disclosed in this Medical Form or in an accompanying letter from an appropriate, qualified medical or psychological professional, then:
A. I may, at the sole and absolute discretion of the program, be dismissed from the program prior to departure or returned to the USA at my or my parent's expense, or be treated in the countries I am visiting, at my or my parent's expense, and there shall be no refund of monies paid to this program.
B. 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 my medical history and mental or physical condition.
~ All medication that I take regularly is detailed in this Application Form in the Medical Information Section.
~ If I will be taking prescription medication while on the trip, I will submit a written report giving full details of each medication.
~ I will travel with a written generic prescription for each medication.
~ I must also bring two complete sets of my medications with me if possible.
To be interviewed as participant on the March of the Living, I will submit a signed copy of the March of the Living physical examination form, found on the
website filled out by my personal physician along with a copy of my Immunizations record from my school. Two 2"x2" passport photos, A copy of the current inside picture page of my passport and a copy of my family medical insurance card. Deposit, as noted, is also required.
$6,225 (subject to possible 5% increase by the International March of the Living): (Domestic flights to and/or from JFK airport, if necessary, are NOT included)
~ DUE Immediately
after submitting this "On-Line" Application: $1,000 deposit, of which $250 is a non-refundable registration fee due with complete "on-line" application.
~ DUE DECEMBER 1, 2017
: 50% of balance due.
~ DUE JANUARY 15, 2018
: Remainder of balance due.
I am aware that a late payment fee of 5% of my balance will be assessed if I do not pay my bill, in full, by January 15, 2018.
I am aware that if I request financial assistance, I must complete the required forms and establish a mutually agreeable payment plan.
We will submit the following 6 items before the interview can be scheduled ...
1. Deposit of $1,000.
2. MOL Dallas Medical Form.
3. Copy of Immunization Record (STUDENTS ONLY).
4. Copy of Family Health Insurance Card (front and back)
5. Two - 2 X 2-inch Passport Size Photos. One must be an actual legal photo.
6. Copy of "inside picture page" of your passport. IMPORTANT: Due to Homeland Security Rulings, the passport must expire after October 23, 2018
I have read my child"s statement above. I agree to all its content and conditions.