REGISTRATION TO THE RELIGIOUS STUDIES FIELD WORKSHOP IN JERUSALEM

THE MARTIN BUBER INSTITUTE FOR DIALOGICAL ECOLOGY

REGISTRATION TO THE RELIGIOUS STUDIES FIELD WORKSHOP IN JERUSALEM

SPRING BREAK 2011: MARCH 13-20, 2011

COSTS: $2,428.90 (when paying by credit card) or 2,270.00 (when paying without using a credit card) - Prices are based on Double Occupancy (single rooms may be available on an optional basis with a price differential). Price includes lodging for 8 days, 7 nights, 3 daily meals, all program activities, all transfers and transportation to group activities, city tours, cultural events, entertainment, and other included tours and activities.


REGISTRATION INSTRUCTIONS

1. To submit your registration, please print and mail this form to: MBIDE, 635 East 14th St. #11G. New York, NY 10009. USA. Phone: 914-439-7731. If you select to pay for the Workshop using your credit card, please proceed to our secure Google Checkout Buy Now button below and process your deposit payment before mailing the Registration form to us. Upon receipt of your payment, we will  issue a voucher for your deposit.

2. If paying by check or money order, please include your deposit check in the amount of $500.00. Make checks payable to the Martin Buber Institute. You may also pay the deposit by credit card through our secured Google Checkout Buy Now button below.

3. Please also include a photocopy of the photo page of your passport.

Part I: PERSONAL INFORMATION

Full Name:

title:

email address:

phone number:

Date of Birth:

Gender :

Occupation:

Home Address:

City: State: Zip code:

country of residence:

Home Phone:

Cell Phone:

Emergency contact email and phone number:

Fax :

Work Phone:

web site:

Country of citizenship:

Place of Birth:

Passport Number and expiration date:

Please let us know your religious affiliation? (if any):

Please provide us with a brief explanation as to special circumstances or concerns: (special diets, health issues, disabilities, etc.). All information is strictly confidential and it will be used solely for the purpose of arranging for special services as needed.





➢ Need Special Diets?

➢ Taking Medications?

➢ Allergies?

➢ Other Health Issues?

➢ Disabilities?


Part II: Financial information:

Method of payment: Credit Card (please see the secured Google Checkout Buy Now button below), Check, Money Order, Cash, Bank to Bank Wire Transfer to the MBIDE's Bank Account. Make checks payable to: The Martin Buber Institute.

Deadlines: Deposit deadline is November 18, 2010. Balance deadline is January 18, 2011.  

$500.00 - DEPOSIT - FIELD WORKSHOP                    $1,928.90 - BALANCE- FIELD WORKSHOP

Part III: COSTS: $2,428.90 (when paying by credit card) or 2,270.00 (when paying without using a credit card). Prices are based on Double Occupancy (single rooms may be available on an optional basis with a price differential). Price includes lodging for 8 days, 7 nights, 3 daily meals, all program activities, all transfers and transportation to group activities, city tours, cultural events, entertainment, and other included tours and activities.

Payments: A deposit in the amount of $500.00 must accompany this application. Deposits and payments must be made within schedule to insure space in the program and to avoid late penalty charges.

After receipt of registration and deposit a voucher for your deposit will be issued and e-mailed to the email address you provided us in the form.

Hope to see you in Jerusalem!

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Please read and sign the following disclosure statement

Waiver and Release

Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releaser') , resident of__________________________________________to the Martin Buber Institute For Dialogical Ecology (MBIDE) (the 'Releasee').

I, the Releaser, in consideration of my participation in the Martin Buber Institute For Dialogical Ecology (MBIDE) Field Workshop Tour of Jerusalem and its environs, Spring Break 2011: March 13-20, 2011, and run and/or operated by the Releasee, waive, release, and discharge the Releasee and MBIDE , its owners, officers, directors, employees, members, agents, assigns, legal representatives and successors, and all business associates and partners involved in the presentation of the above noted activity and each of them their owners, officers and employees, and any other people officially connected with this event from all liability for or by reason of any damage, loss or injury to person and property, even injury resulting in the death of the Releaser, which has been or may be sustained in consequence of the Releaser’s participation in the activity described above, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely choose to participate. I understand that the Releasee does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur as a result of my participation


Date:

Name of Traveler:

Signature of Traveler



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The Martin Buber Institute For Dialogical Ecology
Hune Margulies, Ph.D., Director