Freegaza - Passenger form

HomePassenger form

Important notice

Before applying for a voyage with freegaza, please read carefully this notice:

/en/join-in/passenger-notice

The previous notice is available in different languages, please choose your language on the top right menu

Title

Last name

First name

Personal information

Age

Date of Birth (YYYY-MM-DD)

Country of origin

Passport information

Country of issue

Passport number

Date of expiration (YYYY-MM-DD)

Home address

Telephone number 1

Telephone number 1 :: with country code

Telephone number 2

Primary email address

Street address 1

Street address 2

City

Postal code

Country

Emergency Contact Information

Name of person we should contact on your behalf in the event of an emergency

What is their relationship to you?

Emergency contact city and country

Emergency contact telephone number

Emergency contact email address

Background Information

Please list your experience working in Palestine, and with Palestinian organizations or campaigns in your local community

What is your profession?

What are your areas of expertise? (please be specific)

Please list all the languages you speak

Please list all your affiliations (political, professional, or activist-based)

Please provide us with a one paragraph biography of you that we can post on our website in the event you travel with us to Gaza

Do you have a preference for which dates you would like to travel to Gaza on?

Are you applying as part of a delegation? (preference will be given to delegations, such as doctors, lawyers, students, teachers, musicians, labor activists, et al, who are traveling to Gaza for a specific purpose, such as do an assessment, consult with colleagues in Gaza, or build on solidarity campaigns)

Yes
No

If yes, who is the primary contact person for your delegation?

Are you planning on staying in Gaza long-term?

Yes
No

If you are planning to remain in Gaza, then you MUST have already made contact with organizations working in Gaza and have a clear plan for what you will be doing there. Please describe the contacts and plans you have already made.

Do you have health insurance that will cover you during your trip to Gaza?

Yes
No

Please provide us with your insurance information, in case of a medical emergency (policy name, number, and insurance contact information)

Please list any physical disabilities you may have (artificial knee or hip, for example)

Please list all medications you are currently taking

Can you swim?

Yes
No

Please also provide us with two, written recommendations from people who have been involved in working with Palestinians and Palestinian organizations. We require their names, telephone numbers and email addresses.

To avoid spam we had to include an image verification: please write the text you see in the image into the text box

Important: before clicking on submit, please save the form using the "save page as" button on your browser, in the File menu. Save the compiled form on your desktop. If something goes wrong during submission return to this page, open the saved form side by side, so you can copy and paste the form content and submit it again.

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