Green Israel Summit Registration

* First & last name:

* Address:

* Phone:

* Phone: :: If you are outside the United States & Canada, please provide your country code as well.

Skype name:

Skype name: :: Skype isn't required, but it can be an easier way for us to reach you.

* E-mail:

* Age:

* Age: :: Please provide the age that you will be at the start of the Summit.

* Employer/position, or school/year:

Special dietary needs:

Other special needs:

Allergies:

Lodging/roommate request:

* Emergency contact name:

* Emergency contact phone number:

* How did you hear about the Green Israel Summit?

* How do you plan to travel to the Summit?

If you are planning to drive, how many people can you take with you in your car?

* What type of prayer services would you like to attend? 2-3 will be offered depending on demand:

* What type of prayer services would you like to attend? 2-3 will be offered depending on demand: :: You can check as many as you like.

* Would you like to lead a prayer service?

Yes
No
Maybe if there is no one else to do it

* Would you like to volunteer with the Green Zionist Alliance?

Yes
No
Maybe

Is there anything else that you want us to know?

* Do you have a criminal history?

Yes
No

If yes, please explain:

* By checking this box and submitting this form you agree to hold harmless the Green Zionist Alliance, its partner organizations and all of their paid and nonpaid workers and board members for any loss or damage, physical, financial or otherwise, that may result from your participation in the Green Israel Summit. You also agree to complete a follow-up survey after the Summit's completion.

I understand and accept these conditions of my registration and participation.

* As a security measure, please type the CAPTCHA that's shown to the right.

* As a security measure, please type the CAPTCHA that's shown to the right. :: This is a CAPTCHA -- it's designed to ensure that you're a human and not some zombie computer!

* Are you a paid-member of the GZA for the current secular calendar year?

Yes
No

* Are you a paid-member of the GZA for the current secular calendar year? :: To join, click on "Join" in the top left-hand corner.

* How are you registering?

$225: GZA Member (By Sept. 22)
$300: Non-Member (By Sept. 22)
$350: Late GZA Member (After Sept. 22)
$525: Late Non-Member (After Sept. 22)

Clicking "Register & Pay" will take you to the Donate page, where you will need to enter your registration amount and payment information. Designate the donation as "Green Israel Summit registration." Your registration is not complete until after your payment has been made.

* Designates a required field.

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