Saturday, May 19, 2012
       
   
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.

Program and Preferred Dates
*
* How did you hear about the Program?

Please enter the name of the referring individual or organization, if applicable
:

If applicable, please list the names of people you know who have participated on this program in the past:

General Information
* First Name:
* Last Name:
* Date of Birth: (mm/dd/yyyy)
Passport No:
Exp. Date: (mm/dd/yyyy)
Full Name on Passport:
* Gender:
* Country of Birth:
Contact Information
* Address:
* City:
* State/Province:
* Zipcode:
* Country:
Phone Number: (###-###-####)
* Cell Phone: (###-###-####)
Work Phone: (###-###-####)
* Email:
* Marital Status:
Family Background
* Mother's Name:
Mother's Occupation:
* Father's Name:
Father's Occupation:
* Parents' Marital Status:
* Was your father born Jewish?

Please summarize conversion

history if any:


* Was your mother born Jewish?

Please summarize conversion history if any:


* Parents Jewish affiliation:
Educational History
* How many years of education (starting with first grade) completed?
* What extracurricular activities, hobbies and organizations are you involved in? Please describe your participation in them:
Jewish Background
* What Jewish Education have you had?
If you attended afternoon Hebrew School, how many years did you attend?
What was the Jewish Affiliation of your
Hebrew School?
If you attended Day School, how many years
did you attend?
What was the Jewish Affiliation of your
Day School?
*
Your Current Jewish Affiliation:
*
How would you describe your Hebrew speaking skills?
*
How would you describe your Hebrew reading skills?
* Do you hold any leadership/professional positions in Jewish organizations?
Position:
* Have you been to Israel before?
In What Context?
(Bar/Bat Mitzvah, Year abroad, March of the Living, birthright israel, Yeshiva study, etc.)
*
What types of Jewish experiences
have you had?
(Bar Mitzvah, youth group, /sorority, etc)
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

Reference 1

Name:

Relationship:

Address:

Phone #:

Email:

Reference 2

Name:

Relationship:

Address:

Phone #:

Email:

Best time to reach him/her:

Special Requirements

*
Do you have any accessibility requirements or physical limitations or restrictions?

If so, please elaborate:

*
Do you have any special dietary requirements?
If so, please elaborate:
*
Are you currently taking any medication?
If so, please elaborate:
*
Have you ever been hospitalized?
If so, please elaborate:

An interview is required for all qualified applicants.

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Changes to this Statement

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