Civil Rights Mission Registration

Please note that you are required to complete two forms to finalize your registration. After you complete this form, you will be directed to a separate payment form. Registration is not complete until you have paid the deposit.

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* 1. Personal Information

Title

First Name *

Middle Initial

Last Name *

Name as you would like it on your name tag. *

Birth date *

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* 2. Email Address

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* 3. Room Request

Single (Single supplement charge of $325 per person)

Double

If requesting a double room, please provide roommate’s name:

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* 4. Do you have any dietary requests? Kosher; vegetarian; other (please specify)

Yes

If Yes, please specify.

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* 5. Medical information: Please list all allergies, prescriptions and medical conditions.

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* 6. Emergency Contact (must be an adult not on the Mission)

Name

Phone Number

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* 7. I understand that participation in this Mission requires a minimum commitment of $1,800 each year to the 2020 and 2021 Federation Community Campaigns (or $500 for young adults ages 22-45 at the time of the Mission.)

Yes

Please note that you are required to complete the payment form to finalize your registration. You will be redirected to the payment form to pay a deposit. Registration is not complete until you have paid the deposit.

If you have any questions, please contact Becca Hurowitz at bhurowitz@jfedpgh.org or 412-992-5226.

You will automatically be redirected to https://jfedpgh.org/civil-rights when you click "Proceed to Payment".