December 2024
Trip Participant Forms

National Black Empowerment Council
Leadership Trip to Israel

Please complete this form as soon as possible. By doing so you are confirming your participation on this trip, and we will secure your air transportation and hotels based on this information. You will not be considered confirmed until we have received this form and emailed you your confirmation.

PLEASE NOTE: Confirmations are on a first-come, first-serve basis.

In addition, elected or appointed officials need to certify that their participation complies with applicable ethics laws. Please inform us immediately if there are any changes. Any questions please contact Marvel Joseph at marvel@thenbec.org

First Name

Middle Name

Last Name

Suffix

Name for Badge (Please include any titles)

Preferred Email

Phone

Birthday

Mailing Address

Domestic Departure Airport

Domestic Return Airport

Emergency Contact Name

Emergency Contact Phone Number

Passport Number

Country of Issuance

Passport Expiration Date

Please upload a photo of your passport

Company Name

Position

Official Bio

Have you ever visited Israel?

Yes No

If yes, when and under what auspices?

Have you ever visited any Arab countries?

Yes No

If yes, please list the countries.

Do you have any dietary restrictions?

Yes No

If yes, please provide restrictions.

Trip Safety Waiver

By pressing submit, I herby certify that all information provided is accurate.

I hereby acknowledge and accept full responsibility for my decision to voluntarily enter Israel. I understand the inherent risks and dangers associated with this, including but not limited to, potential injury, loss of life, and psychological trauma.

By signing this waiver, I release and discharge the National Black Empowerment Council from any and all liability, claims, demands, actions, or causes of action whatsoever arising out of or related to my presence in Israel, including but not limited to, any injury, loss, damage, or harm that may occur.

I affirm that I am of legal age and sound mind to make this decision. I understand that this waiver is legally binding and shall remain in effect for the duration of my presence in Israel.

December 2024
Trip Participant Forms

National Black Empowerment Council
Leadership Trip to Israel

Trip Safety Waiver

Support the Cause

Address

Email

Contact Us

December 2024 Trip Participant Forms

National Black Empowerment Council Leadership Trip to Israel

Trip Safety Waiver

Support the Cause

Address

Email

Contact Us

December 2024
Trip Participant Forms

National Black Empowerment Council
Leadership Trip to Israel