UJA-FEDERATION OF NEW YORK MISSIONS APPLICATION

UJA-FEDERATION OF NEW YORK MISSIONS APPLICATION WOMEN S EXECUTIVE CIRCLE MISSION TO RUSSIA SUNDAY, APRIL 22 SUNDAY, APRIL 29, 2018 1. Please reserve space(s) for the mission. I am paying a deposit of $ at $1000* per person. My check is enclosed. Please charge my: MasterCard Visa American Express Discover I hereby authorize UJA-Federation of New York to charge my credit card provided below. I understand that these payments are necessary in order to reserve my trip. I further recognize that these payments are for services (hotels, meals, and so forth) and are not charitable contributions. Please see costs sheet for full details. Any further charges while you are abroad will be charged to your card after you return. on Credit Card Signature Billing Address Card # Exp. Date *The $1000 deposit per person will be charged on receipt of your application. There will be a 2 nd installment of $2500 charged within two weeks of receipt of your application. The remaining cost will be charged 30 to 45 days before departure. All other charges including, but not limited to, charges incurred subsequent to the start of the mission, such as incidentals, deviation fees, and differences in airfare caused by a change in the participant s flight or itinerary will be charged after the conclusion of the mission. You may pay by check, but note that all payments must coincide with the payment schedule. 2. (s) LIST FIRST, MIDDLE AND LAST NAMES EXACTLY AS THEY APPEAR ON YOUR PASSPORT. If there is any discrepancy between the names listed here and the names on your passport, your airline ticket may not be valid and you may have a problem at the airport. Passport must be valid for six months past the return date of this mission. Mr. & Mrs. Mr. & Ms. Mr. Mrs. Ms. Other: Principal (FIRST, MIDDLE AND LAST NAMES MUST BE EXACTLY AS WRITTEN ON PASSPORT) First Middle Last (please specify) Passport # Issue Date (m/d/y) Place of Birth Place of Issue and Citizenship Expiration Date (m/d/y) Date of Birth (m/d/y) Spouse/Guest (FIRST, MIDDLE AND LAST NAMES MUST BE EXACTLY AS WRITTEN ON PASSPORT) First Middle Last Passport # Issue Date (m/d/y) Place of Birth Place of Issue and Citizenship Expiration Date (m/d/y) Date of Birth (m/d/y) Relationship to Principal 1

3. Home Information Street Apt. City State Zip Phone Cell Fax E-Mail(s) Business Information (principal) Profession Title Firm Street Floor/Suite City State Zip Phone Fax E-mail Business Information (spouse/guest) Profession Title Firm Street Floor/Suite City State Zip Phone Fax E-mail Please specify your primary mailing address: home business (principal) business (spouse/guest) 4. Medical Information (required for each participant listed on application) (Rating guide: 1 = poor walker; 2 = difficulty with distances or steps; 3 = fairly comfortable; 4 = average walker; 5 = walks with ease; 6 = able to hike) Health Issues Medicine Rate your level of mobility: Health Issues Medicine Rate your level of mobility: IMPORTANT: HEALTH INSURANCE IS NOT PROVIDED FOR MISSION PARTICIPANTS. If you want to be insured for medical care during the mission you must make your own arrangements we suggest checking possible coverage by your current insurance first. 5. Emergency Contacts (required) Business Phone E-mail Business Phone E-mail Relationship to Participant(s) Home Phone Cell Phone Relationship to Participant(s) Home Phone Cell Phone 6. Religious Background (required for each participant listed on application) Are you Sabbath Observant? Yes No Do You Use Transportation on Shabbat? Yes No Comments Dietary Restrictions: Kosher? Yes No Vegetarian? Yes No Vegetarian, will eat fish? Yes No 2 Are you Sabbath Observant? Yes No Do You Use Transportation on Shabbat? Yes No Comments Dietary Restrictions: Kosher? Yes No Vegetarian? Yes No Vegetarian, will eat fish? Yes No

7. Flight Arrangements Mission programming will begin at 12:00pm in the lobby of the Moscow Hotel on Monday, April 23 rd and will conclude after dinner on Saturday, April 28 th. Participants are responsible for booking their own flights and may contact our travel agent, Claude Hakim for assistance. We wish to be contacted for assistance with flights (Claude Hakim, Field Travel: 718.575.9800, mrfield@verizon.net) We will arrange our own flights. Here is our flight itinerary (required): Arrive Moscow: Depart St. Petersburg: Service Class Economy Business/First Service Class Economy Business/First 8. Rooming Arrangements Standard rooms have been confirmed at the hotels. If you wish to upgrade your hotel room, please contact Jacob Velleman (1.212.836.1761, vellemanj@ujafedny.org) to discuss pricing and availability. Variances in cost will be detailed on your bill. All costs subject to confirmation and booking. Please select a type of room: Single room (additional single supplement will apply) OR Double room I would like to room with (if other than spouse/guest) If possible, please arrange for non-smoking room I will arrive and/or depart before/after the mission dates. Please arrange my hotel reservation(s) as follows: (additional costs will apply) Check in: (date/time) Check out: (date/time) 9. Airport Transfers Individual airport transfers may be arranged at an additional cost and will be added to your bill. Costs will be confirmed as services are requested. Groups of participants arriving and/or departing on the same flight(s) will be transferred together and costs will be divided. Please arrange for transfers. All flight details must be provided in section 6. Please select as many as required. Transfer from the airport to the mission hotel. Exact meeting point TBA Transfer from the mission hotel to the airport. You will be picked up three hours before your flight if economy or two hours before your flight if business/first class. Other If you would like to be dropped off or picked up at a place other than the hotel, specify the exact address and times. Pick up from: Transfer to: Date: Contact number (must be provided): Time: 3

10. PHOTO/IMAGE RELEASE I hereby grant the permission, without reservation, to UJA-Federation of New York to take and to use photographs and/or sound/image recordings of me to describe and to use the same for promotion of good will, public education, and/or fundraising and other related activities of UJA-Federation of New York, and I waive any right to inspect or approve the photograph(s) or finished version(s) of works, including a website, incorporating the photograph(s). I release UJA-Federation of New York and its officers, trustees, agents, employees, independent contractors, licensees, and assignees, including photographers, from all claims I may have or might have for any cause of action arising out of taking and/or use of the photographs and/or any sound/image recordings, and/or descriptions of the same, be it blurring, distortion, alteration, optical illusion, or use of a composite, whether intentional or otherwise, that may occur or be produced in the taking of photographs, or any processing toward the completion of the finished product, unless it can be shown that they and the publication thereof were maliciously caused, produced, and published solely for the purpose of subjecting me to conspicuous ridicule, scandal, reproach, scorn, and indignity. I recognize that UJA-Federation of New York owns the copyright (or may apply for the copyright) of these photographs and other works and creations, and I hereby waive any claims I may have based on any usage of the photographs or works derived therefrom in any form, whether it be printed, projected, televised, or transmitted via the Web, or/and at anytime, be it in the present or in the future, including, but not limited to, claims for either invasions of privacy or libel. I am of full age and competent to sign this release. I agree that this release shall be binding on me, my legal representatives, my heirs, and my assigns. I have read this release, and I fully understand its contents. 11. SECURITY NOTICE AND DIRECTIVES TO MISSION PARTICIPANTS UJA-Federation of New York is vitally committed to the people of Israel and Jewish communities worldwide. We have pledged to stand with the people of Israel and other communities during the trying days of the current crisis and terrorist violence by continuing to send missions to Israel and elsewhere. You have expressed your own commitment and love for the people of Israel and other communities by your deciding to join us, and we are deeply grateful. We are committed to providing you a meaningful mission experience. Toward this end, the itinerary of every UJA-Federation Mission to Israel and elsewhere is subject to very careful, expert scrutiny by security officials. We will visit specified sites only once we have received that security clearance, and we will cancel any visits that the security officials tell us may pose a potential danger. We take these steps, and adhere firmly to them, to protect you. The same prudence is to be exercised by all mission participants. It is requested that you abide by all guidelines and instructions given to mission participants by UJA-Federation of New York s representative offices during your stay. When we warn against visiting certain areas that we have been advised could be dangerous, it is firmly required that you honor these directions; should you elect otherwise, you should recognize that your safety could be imperiled and that you may be exposed to greater risk. Further, if you request an itinerary change that extends beyond our carefully developed and monitored security guidelines and program capability, our Missions Department and/or our Israel Office will not accommodate said requests. Questions about this may be directed to UJA-Federation of New York s Missions Department. Notwithstanding the above, if on your own accord you elect to make unilateral arrangements for a mission itinerary component outside of our security guidelines and program capability, we will ask to be kept apprised so that our missions office team can maintain contact with you at all times while you are away. We will use the training, good judgment, and experience of our overseas colleagues, overseas representative offices, and our entire Missions Department to seek to reward your expression of commitment to the people of Israel and elsewhere with a trip that is meaningful, fulfilling, and protective of your safety. These objectives will be accomplished if we have your trust and full cooperation in implementing this mission security protocol. 12. NOTICE OF RISKS OF TRAVEL, RELEASE, AND SIGNATURE I am aware of the risks of foreign travel, including risks associated with my safety and security. I have read, or have had the opportunity to read, the United States Department of State s Worldwide Caution notice found at https://travel.state.gov/content/passports/en/alertswarnings/worldwidecaution.html. These risks include, but are not limited to, property damage and loss, death, or injury by accident, disease, or terrorist acts. I am voluntarily participating in the United Jewish Appeal Federation of Jewish Philanthropies of New York, Inc. ( UJA-Federation ) Mission ( Mission ) with a full understanding of these risks, and I assume and agree to accept all risks to my safety and security during the course of participating in the Mission. I acknowledge and affirm that, notwithstanding any security arrangements that may be made by UJA-Federation or any other party, UJA-Federation does not guarantee and is not responsible for my personal safety and my property while participating in the Mission or any Mission-related activities, including, but not limited to, airline travel, ground transportation, meals, lodging, and recreational activities, to include the activities of this particular Mission as described on the attached itinerary and/or in other materials distributed in connection with this Mission, including but not limited to, for example, cleanup and refurbishing of sites in Israel. In light of the above and in consideration of being permitted to participating in the Mission, I do, for myself, my spouse, my heirs, my executors, my administrators, and my assigns, release and forever discharge UJA-Federation and its respective subsidiaries, affiliates, predecessors, successors, and assigns, and all of its respective past, present, and future officers, directors, shareholders, employees, agents, and contactors, and their respective heirs, executors, administrators, and assigns (collectively, the Releasees ), of and from any and every claim arising from or by reason of any bodily injury, personal injuries known or unknown (including emotional trauma), death, or property damage resulting or alleged to result from any accident, or other episode that may occur, whether based on the negligence of, or the breach of contract by, any Releasee or any other party for whose acts may be responsible in law or in fact, or any other cause or principle of law, as a result of my participation in the Mission or any activities in connection with the Mission. 4

This release contains the entire agreement between the parties to this release. This release supersedes any prior or contemporaneous agreements, understandings, and negotiations regarding its subject matter. This release shall be interpreted and enforced in accordance with the laws of the State of New York, and shall be as broad and inclusive as permitted by such laws. If any provisions of this release are held invalid, it is agreed that the balance shall notwithstanding continue in full force and legal effect. I have carefully read the foregoing release and understand its contents, and acknowledge that this is a release of liability and, as such, is a binding and fully enforceable contract between me and UJA-Federation. 13. CANCELLATION PENALTIES (all penalties are per person) UJA-Federation has paid non-refundable deposits for the hotel rooms; therefore, the $1000 deposit is non-refundable. If the participant(s) cancels within 30 days of receipt of the application, any payments, other than the $1000 deposit, will be refunded. After that, there is no refund. There may be additional fees equal to the actual costs, including monetary penalties assessed and charged to UJA-Federation by the airlines and/or hotels and/or land operators. UJA-Federation does not assume responsibility for any penalties assessed by the airlines due to changes and/or cancellations of the flights or the mission. If you depart from the trip en route, UJA-Federation will not refund the cost of any unused transportation, hotel reservations, sightseeing, meals or any other tour services. We strongly suggest you purchase travel and trip cancellation insurance. 14. SIGNATURE(S) OF ALL ADULTS NAMED ON THIS APPLICATION Print (s) Signature(s) Date UJA-Federation of New York reserves the right to limit participation based on eligibility requirements, space availability, and other criteria that it may determine in its sole discretion. In addition, UJA-Federation of New York reserves the right to terminate the participation of any mission participant whose behavior, in its sole discretion, is determined to be detrimental to the health, safety, or well-being of other participants and/or to the organization. Generally, under the Internal Revenue Code, any contribution that you make to UJA-Federation is deductible only to the extent that it, plus your payments for this mission, exceed the benefit received (in other words, the fair market value of the mission). In addition, any payments for extra air and/or land costs are not tax-deductible. YOU MUST SUBMIT A COPY OF THE SIGNATURE/PHOTO PAGE OF YOUR PASSPORT WITH THIS APPLICATION A VISA IS REQUIRED FOR TRAVEL TO RUSSIA; ALL PARTICIPANTS MUST PROCURE THEIR OWN VISA Submit this form by scan/email, mail, or fax: Scan/email: zelinn@ujafedny.org Fax: 1.212.836.1738 Mail: Missions Department, 130 East 59 th Street, New York, NY 10022 For more information please contact: Andrea Gingold at 212-836-1187 or gingolda@ujafedny.org 5