AEPi Israel SOLIDARITY MISSION
Registration

Personal Information
Name (as listed exactly on Passport)(Required)
First Last
Middle Name (as listed exactly on Passport)
Middle
Email(Required)
Phone(Required)
Gender(Required)
Date of Birth(Required)
MM slash DD slash YYYY
T-shirt Size(Required)
Emergency Contact Information
Emergency Contact Name(Required)
First Last
Emergency Contact Relationship(Required)
Emergency Contact Email(Required)
Emergency Contact Phone Number(Required)
Medical Information
Physician Name
Prefix First Last
Physician Email
Physician Phone Number
Do you have any allergies? If yes, please list your allergies:(Required)
Write N/A if not applicable
Are you currently taking medications? If yes, please list your medications:(Required)
Write N/A if not applicable
Do you have any medical restrictions? If yes, please list your medical restrictions:(Required)
Write N/A if not applicable
Do you have any dietary restrictions? If yes, please list your dietary restrictions:(Required)
Write N/A if not applicable
Passport Information
Passport Number(Required)
Passport Issue Date(Required)
MM slash DD slash YYYY
Passport Expiration Date(Required)
MM slash DD slash YYYY
Passport Issuing Country(Required)
Please upload a copy of your passport:(Required)
If you are filling out this application on your phone: Take a picture of your passport using the Camera app on your phone. In the application, select "Choose File" and select the picture you took of your passport. If you are filling out this application on your computer or laptop: Take a picture of your passport using the "Camera" app on your phone. After taking the picture, send the picture from your phone over email to yourself. On your computer, open the email containing the picture that you emailed yourself. Save this picture to your desktop. On this application after taking the photo of your passport, select "Choose File" and select the picture you took of your passport. If you have any questions with attaching your passport, please contact Zachary Sachs at 954-850-4561
Max. file size: 128 MB.
Payment Information
How would you like to pay?(Required)
- Pay in Full - $3,875
- Installments: Deposit of $975 charged today, $1450 charged on May 15, $1450 charged on June 1
- I will mail a check to the AEPi Foundation (8815 Wesleyan Road, Indianapolis, IN 46268)
Subtotal
$0.00
Credit Card Fee
$0.00
Credit Card(Required)

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Transaction Total
$0.00
Note: A credit card is required to submit the form. If you selected to mail a check, a card is required but you will not be charged.
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Chapter
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Graduation Year
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Preferred Contact Time

AEPi Israel SOLIDARITY MISSIONRegistration

Personal Information

Emergency Contact Information

Medical Information

Passport Information

Payment Information

Note: A credit card is required to submit the form. If you selected to mail a check, a card is required but you will not be charged.

AEPi Israel SOLIDARITY MISSION
Registration