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ISRAEL YESHIVALITE SUMMER '12 SESSION
Please
fill in all the required information (as denoted by
*
), otherwise your application will not be accepted.
After submitting this application you will automatically
receive a confirming email. Please notify us if you
have any questions or with address or phone number changes at
www.yeshivalite.org or call 248-789-9199.
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Program and Preferred Dates
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How did you hear about the Program?
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Please enter the name of the referring individual or organization, if applicable
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If applicable, please list the names of people you know who have participated on this program in the past:
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General Information
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First Name:
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Last Name:
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Date of Birth:
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(mm/dd/yyyy)
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Passport No:
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Exp. Date:
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(mm/dd/yyyy)
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Full Name on Passport:
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Gender:
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Country of Birth:
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Contact Information
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Address:
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City:
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State/Province:
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Zipcode:
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Country:
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Phone Number:
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(###-###-####)
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Cell Phone:
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(###-###-####)
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Work Phone:
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(###-###-####)
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Email:
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Marital Status:
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Family Background
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Mother's Name:
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Mother's Occupation:
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Father's Name:
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Father's Occupation:
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Parents' Marital Status:
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Was your father born Jewish?
Please summarize conversion
history if any:
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Was your mother born Jewish?
Please summarize conversion history if any:
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Parents Jewish affiliation:
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Educational History
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How many years of education (starting with first grade) completed?
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What extracurricular activities, hobbies and organizations are you involved in? Please describe your participation in them:
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Jewish Background
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What Jewish Education have you had?
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If you attended afternoon Hebrew School, how many years did you attend?
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What was the Jewish Affiliation of your
Hebrew School?
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If you attended Day School, how many years
did you attend?
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What was the Jewish Affiliation of your
Day School?
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Your Current Jewish Affiliation:
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How would you describe your Hebrew speaking skills?
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How would you describe your Hebrew reading skills?
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Do you hold any leadership/professional positions in Jewish organizations?
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Position:
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Have you been to Israel before?
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In What Context?
(Bar/Bat Mitzvah, Year abroad, March of the Living, birthright israel, Yeshiva study, etc.)
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What types of Jewish experiences
have you had?
(Bar Mitzvah, youth group, /sorority, etc)
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References
Please include name, address, phone, relationship to you and the best time of day he or she can be reached. Please do not include family or friends
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Reference 1
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Name:
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Relationship:
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Address:
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Phone #:
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Email:
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Reference 2
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Name:
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Relationship:
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Address:
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Phone #:
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Email:
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Best time to reach him/her:
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Special Requirements
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Do you have any accessibility requirements or physical limitations or restrictions?
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If so, please elaborate:
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Do you have any special dietary requirements?
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If so, please elaborate:
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Are you currently taking any medication?
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If so, please elaborate:
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Have you ever been hospitalized?
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If so, please elaborate:
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An interview is required for all qualified applicants.
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