Trip you are applying for: Women's Delegation to Gaza

Departure date: March 5-13, 2014
NOTE: This trip is for women only.

NOTE: Please submit this form only ONCE - the "acknowledgement" page may not appear due to a temporary glitch. Thank you. 

Please complete the following information to join the Gaza Freedom March:
* First Name (as it appears on your passport)
* Last Name (as it appears on your passport)
Name as you prefer to be called:
* Email
Organization
* Occupation
* Home Phone
* Work Phone
Street
* City
State
* Zip
* Country
* Birth Date
* Birthplace
Gender & Ethnic Background (optional)
* Your language abilities other than English: (Please indicate what language and what level- basic, intermediate, conversational or fluent):
Passport Information
* I am a citizen of:
* Passport Number:
* Place of issue:
State, if issued in the U.S. or Canada
* Date Issued:
* Date of Expiration:
Person to contact in case of emergency:
* Name:
* Relation:
* City, State, Country:
* Emergency Contact's Phone:
* Emergency Contact's Email:
Please answer the following questions
* Why do you want to go to Gaza?
* Have you been there before and if so, under what circumstances?
* What do you expect to gain from participating?:
* Please state the ways in which your work/studies/activism relate to the issues or themes pertaining to this trip to Gaza?
* How will you apply your learning experience when you return home?
* We are in regular contact with journalists who want to write stories about our trip. Would you be interested in being called for an interview?

* Give a one-sentence description of yourself to share with other delegates:
* How did you hear about this trip?:
First Name
* Required Field