ISRAEL TOUR MARCH 4-13, 2023

Full Name (as it appears on passport)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Passport Number

Passport Expiration (must be valid six months after return date)

YYYY

Passport Country of Issue

Gender

Female

Male

Payment Plan

The price is $4,750 per person for the tour to Israel. I understand that our deposit is due by Jan 6, 2023 and will be used to guarantee the airfare and hotel space and that full deposit of $1,500 is nonrefundable. I also agree with the payment schedule as follows: Venmo payments are preferred @natemchenry OR Checks must be made payable to Heartworkmissions with "Israel Tour" noted on the memo. Mail checks to: Heartwork Missions PO Box 727 Windsor, CO 80550 First Payment of $1,500 (non-refundable) due Dec 31, 2022 Second Payment of $1,500 due Jan 20, 2023 Final Payment of $1,750 due Feb 17, 2023 Type your full name below to agree to the payment plan.

Do you have any health problems or special needs?

Do you have any special dietary needs?

Are you taking any forms of medication? Please list and explain why they are required.

Are you allergic to anything?

Emergency Contact

Someone not on the trip with you

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Rooming with (list name below or please help me find a roommate (state below). I prefer a single room ($590 additional cost).