E4 – Galilee : Application
Summer 2020

Dates: August 1st , 2020 – August 14th , 2020
Price: $5,000

For more information, please contact Rami Nuseir:
Mobile: +1 (347) 924-9674
Email: rami@amln.org


    Student Information:

    Please enter your full name, as it appears on your passport.

    Address:

    Personal Essay:

    In 500-750 words, explain why you wish to participate in E4 Galilee, what you expect to take away from it, and how you envision to put these learning to use.

    Passport Information:

    123

    Passport 1:

    Passport 2:

    Passport 3:

    Emergency Contacts:

    Please provide at least two emergency contacts. All emergency contacts must be adults (above the age of 21). One of them must be your guardian.

    Emergency Contact #1: Primary Guardian

    Emergency Contact #2:

    Emergency Contact #3: (Optional)

    Allergies & Special Conditions:
    NoYes

    Please check all the applicable items and list any others.

    AspirinIbuprofenOther
    NoYes

    Please check all the applicable items and list any others.

    PeanutsNutsSesameWheat/GlutenShellfishFishDairySoyOther
    NoYes

    Please check all the applicable items and list any others.

    DustPollenGrassOther
    NoYes

    NoYes

    Please check all the applicable items and list any others.

    PorkDairyOther
    NoYes

    Please check all the applicable items and list any others.

    AsthmaDiabetesHigh blood pressureLow blood pressureSinusitusEczemaOther
    NoYes

    Please check all the applicable items and list any others.

    InsulinAsthma inhalerEpinephrine shots (EpiPen)Other
    NoYes

    Please check all the applicable items and list any others.

    Motion sicknessFear of heightsOther