Leadership Mission to Israel Payment Form

Consent*

By checking this box, I acknowledge and represent that I am at least eighteen (18) years of age and that I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by agreeing to these terms, and agree to them freely and voluntarily without any inducement.

LIABILITY ACKNOWLEDGEMENT AND WAIVER

By submitting this application, I acknowledge that I have read, understood, and agree:

1. There are certain risks that may occur from participating in this mission to Israel during a War, including but not limited to injury, illness, permanent trauma, kidnapping, or death; and,

2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation; and,

3. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless the Union of Orthodox Jewish Congregations of America (the “Orthodox Union”), their respective officers, directors, trustees, affiliates, agents, employees, independent contractors, consultants, advisors, vendors, volunteers, licensees and assignees (collectively “releasees” and each a “releasee”) from and against every claim, loss, damage and liability or responsibility, including, without limitation, reasonable attorneys’ fees and costs (“liabilities”) arising with respect to any and all injury , disability, death, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.

Media Release*

By checking this box, I acknowledge and represent that I am at least eighteen (18) years of age and that I have read the THE ORTHODOX UNION MEDIA RELEASE, and that I understand it and sign it voluntarily.

ORTHODOX UNION MEDIA RELEASE
From time to time, The Union of Orthodox Jewish Congregations of America, and its programs, employees and agents (together, the “Orthodox Union”) take photographs and videos of individuals, including minors, who attend or participate in Orthodox Union events, programs, and other offerings. The Orthodox Union engages in these activities for purposes relating to the advancement of the religious, spiritual, charitable, and educational goals and objectives of the Orthodox Union, including but not limited to the sharing of photos/videos in newsletters, on our blogs, and on our website and social media pages for the purpose of keeping our members and others informed of the Orthodox Union’s events and other activities. Please complete this form to give us permission to take photos/videos of you and/or your children when you participate in Orthodox Union events or programs and to use those photos/videos in our printed and online publicity:

I hereby authorize the Orthodox Union to take photographs and/or video of me (or my children) when I (or my children) participate at Orthodox Union events or programs. I grant the Orthodox Union full rights to use and share the images resulting from the photographs and/or videos and any reproductions thereof (the “Recording”), in whole or in part, along with my (or my children’s) name, biographical information and quotations for any purpose including fundraising, publicity, advertising, or on social media, all without further obligation or compensation. I hereby waive any right of review or approval regarding the Recording and the Orthodox Union shall have the right to edit or delete the Recording in its sole discretion. I understand that all rights in and to the Recording shall be the Orthodox Union’s sole and absolute property. I understand that if I access the Orthodox Union’s services through a third party platform, product, service, or application (a “Third Party Service”), content and related information generated while accessing OU’s services in this manner may be monitored, captured, and or recorded by the third parties that provide such Third Party Services. I consent to the use and sharing of personal information by any such third party as described in the privacy policy available through the Third Party Service. I release and forever discharge the Orthodox Union from all causes of action, suits, or liability of any kind arising from or in connection with the use or publication of any Recording of me or my children made in connection with my participation in Orthodox Union events. I waive any right of privacy associated with the Recording and I waive any right to compensation related to the use of the Recording.
I HAVE READ THIS AGREEMENT AND AM FULLY AWARE OF ITS CONTENTS, INCLUDING THE RELEASE THAT I HAVE AGREED TO HEREIN.
I warrant that I am at least eighteen years of age (or, if not, that my parent or legal guardian has agreed to the foregoing and signed below) and that I have the full and unrestricted authority to enter into a contract for myself (or, if not, that my parent or legal guardian has agreed to the foregoing and signed below).
If any provision of this agreement is held to be unenforceable, the remainder of it shall continue to be in full force and effect.
This waiver shall remain in effect until such time as I advise the OU otherwise in writing.

Program Registration

Name*

First Last

Legal Name (if different from above)

First Middle Last

Email*

Cell Phone - USA*

WhatsApp number in Israel if different than above

Address (if different than billing address below)

If your home address is the same as you billing address, you may skip this question.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nationality*

Passport Number*

Passport Expiration*

Please note- this is in the Israeli format of Day, Month Year

Date of Birth*

Please note- this is in the Israeli format of Day, Month Year

Departure flight information (US to Israel)*

Airport	Flight #	Departure time	Arrival time

Return flight information (Israel to US)*

Flight #	Departure time	Arrival time

Name of Shul*

Communal role*

Rebbetzin
Lay Leader

Title and description of role and communal involvement*

Please share any food allergies

Please list any important information you would like the trip organizers to know

Emergency Contact

Emergency contact name

First Last

Relationship

Cell phone

Email

Payment

Mission cost includes hotel (single occupancy), food, transportation and all other trip related costs. It does not include flights. For the duration of the mission, rooms and meals are only available to mission participants.

Cost - $1800*

Trip cost - $1800

Coupon

Total Cost

$0.00

Billing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

This field is for validation purposes and should be left unchanged.

Leadership Mission to Israel Registration Form

Program Registration

Emergency Contact

Payment