PANA Pilgrimage to Manzanar 2009 - application form

Pilgrimage dates: April  23-26, 2009

Please email or print & give this form to Rev. Deborah Lee at the PANA Institute by April 4, 2009.

Rev. Deborah Lee
PANA Institute
1798 Scenic Ave.
Berkeley, CA 94709

For questions, please contact Deborah Lee at dlee@psr.edu or (510) 849-8260.  

One person per form.

1.  Participant Name:

2. Contact information:

Address:

City, ST, Zip:

Telephone:

Cell:

Email:

3. Written questions: 

Please use an additional sheet of paper (or add space to this file.)

1. Tell us a little about yourself and how you connect to the themes of the pilgrimage to Manzanar, Japanese internment, WWII.
2. What are your hopes and motivations for going on this pilgrimage?
3. Is there any way we can help you in your preparation for the pilgrimage?
4. Let us know any concerns or questions that you have.

4. Any special dietary or other needs? Yes / No
If yes, explain:

5. In case of emergency:

5a. Emergency Contact (someone who will NOT be on the trip):

Name:

Phone:

5b: Other Medical:

Name of Physician: 

Physician Telephone:

Other medical information we should know:

 


Media Waiver and Release:  

For the duration of the Pacific School of Religion Pilgrimage to Manzanar course and event, photographs, interviews and videos of participants may be taken for publicity, informational and educational purposes. I grant permission for the use of my photos, interviews and videos while participating in the program.    

 
Signature:


Cost of the Trip

Total costs are partially subsidized by the PANA Institute’s Civil Liberty and Faith Project. The options for costs are as follows (including food, transportation and other fees):

(1)    $264:  Including 3 nights of hotel (1 person per bed; 2 people per room)
(2)    $245:  Including 3 nights of hotel; shared beds at Travelodge Hotel (2 people per bed, 4 people per room)
(3)    $154:  1 night of hotel in Travelodge and camping in Independence (Camp out 2 nights in Independence)

Please include $100 deposit with this application form due by April 4, 2009. The remainder is due by April 17th.  Check, credit card or cash is accepted.  Please make the check payable to “Pacific School of Religion”  with memo "PANA Manzanar" and send to PANA, 1798 Scenic Ave., Berkeley, CA 94709.