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Alternative Break Application-March 2018 trip to Houston
Name
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First Name
Last Name
Email
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Verify Email
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Home Mailing Address
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Cell Phone
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Date of Birth
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(mm/dd/yyyy)
Graduation Year
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Parent(s) Name(s)
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First Name
Last Name
First Name
Last Name
Parent(s) Email(s)
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Verify Email
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Verify Email
Emergency Contact Information
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First Name
Last Name
Emergency Contact Phone
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Relation to you
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Health Insurance Carrier
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Health Insurance Policy Number
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List any allergies or limiting medical conditions you may have
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Is your tetanus vaccine current?
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Yes
No
Why are you interested in participating in Hillel's Alternative Break trip to Houston with Nechama, the Jewish Disaster Relief Organization? What would you add to the group experience? (Please answer in 100- 200 words)
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Please describe past experiences with alternative break trips, disaster relief work, or community service. (Please answer in 100- 200 words)
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What will make you a positive addition to the group? (Please answer in 100-200 words)
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