Board of Directors
2023 Michigan-Israel Women in Mobility Delegation
Thank you for your interest in joining us for our Michigan-Israel Women in Mobility Mission. Please complete the registration form below to join.
MIBA Delegation Registration Page
Name (as it appears on passport)
How you would like your name to appear on your name tag, including credentials, if desired (i.e., PhD, MBA)
Contact Cell Number
This information will be shared with the companies and speakers we will be meeting.
This information will be shared with the companies and speakers we will be meeting. Please briefly mention details about your company, products, and services as well as any other points about your organization that you'd like to highlight.
Indicate your specific business interests and any desired objectives regarding this mission
Examples: Import, export, investment, innovation collaboration interests
Is this your first visit to Israel?
If no, please indicate when you were last in Israel and provide a brief description of the purpose of your visit(s)
Preferred Mailing Address
We send our delegates correspondence primarily by email. However, we also send a welcome package in the mail. Please provide us with the best mailing address to receive a welcome package.
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
French Southern Territories
Heard Island and McDonald Islands
Isle of Man
Korea, Democratic People's Republic of
Korea, Republic of
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syria Arab Republic
Tanzania, the United Republic of
Trinidad and Tobago
Turks and Caicos Islands
US Minor Outlying Islands
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Dietary Restrictions and Allergies
Please list any dietary restrictions or allergies or indicate none
Emergency Contact Information
Contact's Phone Number
Executive Assistant's Name
Executive Assistant's Email
Executive Assistant's Cell Number
Passport and Flight Information
Participant Date of Birth
MM slash DD slash YYYY
Participant Passport Number
Participant Passport Expiration Date
MM slash DD slash YYYY
Photo or Scanned Copy of Passport
Passport details will be required at least 3 weeks prior to the trip. The expiration date of your passport cannot be within 6 months of the trip's departure date.
Max. file size: 50 MB.
Copy of Flight E-ticket
If you have not purchased your flight, details will be required at least 3 weeks prior to the trip.
Max. file size: 50 MB.
I agree to the terms below.
Michigan Israel Business Accelerator (MIBA) 2023 RELEASE OF LIABILITY AND HOLD HARMLESS ("Release"). The undersigned is a participant in the Program and in connection with such participation, hereby states and agrees as follows:
I am at least eighteen (18) years of age, and I am fully competent. I am aware of the risks of travel to Israel and travel worldwide, including risks associated with my health, safety and security. These risks include, but are not limited to, property damage and loss, death or injury by accident, disease, and terrorist acts. I am voluntarily participating in the Program with a full understanding of these risks, and I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me, as a result of my being a participant in the Program however and by whomever caused.
I have read, or have had the opportunity to read, the current United States Department of State’s Travel Warning for Israel, Gaza, and the West Bank at http://www.travel.state.gov. I understand that in advance of the Program, I may periodically check the State Department’s website to see if the Travel Warning has been superseded by a new Travel Warning. I have elected to participate in the Program with full knowledge of the content of such Travel Warning as same may be updated or superseded. I hereby choose to a accept the risk of contracting COVID-19 for myself to attend the delegation. In the event of having to be quarantined past the dates of the delegation, I understand that any expenses will not be covered and will be my responsibility.
I understand that the fee being charged is based on costs associated with travel that we are aware of, and should any new costs related to new or changed Covid protocols be implemented prior to the program, the MIBA may need to pass these unexpected costs on to me.
I acknowledge and agree that, notwithstanding any security or travel arrangements that may be made by MIBA or any other organization engaged by or affiliated with MIBA, these organizations do not guarantee and are not responsible for my personal health or safety or the safety of my property while participating in the Program or any Program-related activities, including, but not limited to, airline travel, ground transportation, meals, lodging and recreational activities.
I acknowledge that MIBA has notified me that I may obtain policies of travel and/or medical expense insurance from a company or organization that provides such coverage (“Policies”) and that some risks of loss and damage may be covered by such Policies, subject to the terms and conditions thereof. If I do obtain such coverage I agree to look to the party or parties providing such coverage for all covered loss and damage under such Policies, but I further acknowledge and agree that the Policies may not cover all risks, and that obtaining such Policies in no way limits my assumption of responsibility for all risks, nor limits in any way any release, waiver or indemnification contained in this document.
In light of the above and in consideration of being permitted to participate in the Program, I do hereby, for myself, my spouse, heirs, executors, administrators and assigns, indemnify, defend, hold harmless, release and forever discharge MIBA their respective subsidiaries, affiliates, predecessors, successors and assigns, and all of their respective past, present and future officers, directors, shareholders, trustees, employees, agents and contractors, and their respective heirs, executors, administrators and assigns (collectively, the “Releasees”), of and from any and every claim, loss, cost, damage and expense (including reasonable attorneys’ fees) arising from or by reason of any bodily injury, personal injuries known or unknown (including emotional trauma), death, or property damage resulting or alleged to result from any accident, incident, or other occurrence, whether based upon the negligence of, or breach of contract by, any Releasee or any other party for whose acts or omissions any Releasee may be responsible in law or in fact, or any other cause of whatever nature or principle of law, as a result of my participation in the Program or any activities in connection with the Program.
This Agreement contains the entire agreement between the undersigned and MIBA regarding the subject matter contained herein. This Release supersedes any prior or contemporaneous agreements and understandings regarding its subject matter. This Release shall be enforced and interpreted in accordance with the laws of the State of Michigan and shall be as broad and inclusive as permitted by such laws. If any provision of this Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and legal effect.
I have carefully read the foregoing provisions of this Release and understand its contents, and acknowledge that this is a release of liability, indemnification and hold harmless agreement and that all of the provisions are binding and constitute a fully enforceable contract between myself and that I have consulted, or have had the opportunity to consult, my own counsel as to its meaning and legal effect and I sign this Release voluntarily as my own free act and deed for full, adequate and complete consideration fully intending to be bound by same.
The all-inclusive land cost for the 2023 Michigan-Israel Women in Mobility Mission is $5,500. Please select your payment preference and you will receive a Quickbooks invoice.
I would like to mail a check.
I would like to send an ACH payment.
I would like to pay by Credit Card (There will be $165 fee on a charge of $5,500)
Email invoice to: