Medical Mission Registration | P2G Western Galilee

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Let's RSVP

First Name

Last Name

Email

Phone

Gender *

Female

Male

Other

Birthday

Local Jewish Federation

Do you have a valid license to practice medcine?

What is your medical field of expertise?

Do you have any allergies? *

Yes

No

What are your allergies?

Dietary needs (All meals are Kosher)

Vegan

Vegetarian (dairy and egg)

Pescatarian

No dietary restrictions

Other

You chose other, please elaborate

Describe your previous experience with Partnership2Gether

Any physical limitations? if yes, please elaborate

Emergency contact name

Emergency contact phone

Emergency contact email

Have you completed your ETA-IL application? As of January 2025 travelers to Israel must have ETA-IL approval before traveling. Please have your passport number available when filling out the application: https://israel-entry.piba.gov.il *

Yes

No

Will you be coming with a spouse? * Required

Yes

No

other

Name of your spouse

You chose other. please elaborate

Upon registering I commit to pay the following amounts for the P2G Pre-summit and Summit (mark all that apply) * Required

Consortium communities Doctors - $200 registration fee

Consortium member non-Doctors - $500 registration fee

Non-consortium communities Doctors - $1,200 registration fee

I have read and agreed to the terms outlined in the waiver form:Release of Liability Waver

I have read and agreed to the terms outlined in thePhoto Consent Form

Thanks for registering!
A confirmation email has been sent to your mailbox

This form no longer accepts submissions.

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