MidEast Citizen Diplomacy - Trip Registration

MidEast Citizen Diplomacy

Please print & carefully fill out the following form, then mail with your deposit.

Trip you are applying for:
Name:
Address:
City:
State:
Zip:
Telephone - Day:
Telephone - Evening:
Email:
Fax:
Date of Birth:
Occupation:
Employer:
Interests/skills:
Ethnic Identity (optional):
Religious affiliation/practice:
Accomodations
I prefer a ___ single room ___ double room
I wish to share a room with:
I am a ___ smoker ___ non-smoker
Country of Citizenship:
Exact name on passport:
Passport number:
Date of Issue (day/mo/yr):
Date of Expiration:
In case of emergency please notify:
Relation:
Phone(s):
Address:
What draws you to the Compassionate Listening Project?
Do you have any special dietary needs, medical conditions, allergies or disabilites that may affect your participation in this trip?
Participants are expected to have good communication skills and a commitment to conflict resolution. What are your strengths in this area?
How did you learn about this delegation?
We will reserve your space on this trip when we have received your application and trip deposit, mailed to MECD.
Deposit paid by __ check enclosed (payable to MidEast Citizen DIplomacy); __ Visa; __ Mastercard.
Amount _________ Card Number ______________________ Exp. Date __________
Print name as it appears on card ________________________ Signature ________________________