Name: _______________________________________________________________

Street Address: _____________________________________________________

City / State / Zip: _________________________________________________

Home Phone: _________________________________________________________

Work Phone: _________________________________________________________

Cell Phone: _________________________________________________________

Occupation: _________________________________________________________

E-Mail Address: _____________________________________________________

Age (as of 7/2/09): _____ Birthdate (MM/DD/YYYY): ____/_____/_______

T-Shirt Size? Circle:    MEDIUM    LARGE    EXTRA-LARGE

Smoker? Circle: YES or NO

Room Preference:

___ Double ($1780) ___ Single ($350 supplement)

Roommate Request: __________________________________________________

(Room share assistance provided, but not guaranteed, particularly for late reservations)

Have you participated in a previous YJLC Pocono Weekend or Israel Encounter? Please circle: YES or NO

(If YES) Previous Pocono Weekend Date (Month / Year): ____/_______

(If YES) Previous Israel Encounter Date (Month / Year): ____/_______

Have you been to Israel on Birthright? YES or NO

(If YES) Month / Year: ____/_______

What organizations are you / have you been involved in:

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

Reference — Please give the name and phone number of a Rabbi or Jewish Community Professional who can vouch for your identity and leadership potential:

Name: ______________________________________________

Phone Number: ____________________

Costs:

$1780 — Land Package

$2995 — Land & Air (note: plus $120 estimated taxes)

$350 — Single Supplement — if you plan NOT to have a roommate

(room share assistance provided, but NOT guaranteed)

$50 — Registration Fee (waived for reservations before May 1)

$50 — Late Registration Fee (for reservations after May 29 — if space is available).

Cancellation Fees:

— Up to 46 days prior to departure — $100

— 45—31 days prior to departure — 50% of cost

— 30 days or less prior20to departure — 100% of cost

Hotel Itinerary: (touring & special events subject to changes)

Thursday, July 2 — Depart US

Friday, July 3 — Arrival — Tel Aviv

Saturday, July 4 — Tel Aviv

Sunday, July 5 — Kibbutz — Galilee

Monday, July 6 — Kibbutz — Galilee

Tuesday, July 7 — Jerusalem

Wednesday, July 8 — Jerusalem

Thursday, July 9 — Jerusalem

Friday, July 10 — Depart

or Extensions— Highly recommended!

Including attending Maccabia Games — the Jewish Olympics

(costs for hotel & touring, figure approx. $200/day)

SAVINGS:

Possible 50% Scholarship through your local Israel Programs Office.

$50 Discount for Reservations before April 3.

$50 Registration Fee WAIVED for reservations before May 1.

$250 Deposit will hold your space.