Program and Preferred Dates
* Program Dates:
Please Select
April 29 - May 17
June 25 - July 12
General Information
* First Name:
* Last Name:
* Date of Birth: (mm/dd/yyyy)
Passport No:
Exp. Date: (mm/dd/yyyy)
Full Name on Passport: (mm/dd/yyyy)
* Gender:
Please Select
Male
Female
* Country of Birth:
Contact Information
* Address:
* City:
* State/Province:
* Zip:
* Country:
Phone Number: (###-###-####)
* Cell Phone: (###-###-####)
Work Phone: (###-###-####)
* E-mail:
* Marital Status :
Please Select
Single
Married
Separated
Divorced
Widowed
Permanent/Parents' Home Address
* Residence of:
Please Select
Self
Parents
Mother
Father
* Address:
* City:
* State/Province:
* Zip:
* Country:
* Phone Number: (###-###-####)
Fax: (###-###-####)
E-mail:
Family Background
* Mother's First Name:
* Mother's Last Name:
Mother's Occupation:
* Father's First Name:
* Father's Last Name:
Father's Occupation:
* Parents' Marital Status :
Please Select
Married
Separated/Divorced
* Was your father born Jewish? Please summarize conversion history if any:
Please Select
Yes
No
* Was your mother born Jewish? Please summarize conversion history if any:
Please Select
Yes
No
* Parents Jewish affiliation:
Please Select
Reform
Conservative
Orthodox
Unaffiliated
Other
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?
Please Select
Virtually None
Hebrew School/Sunday School (pre age-13)
Hebrew School/Sunday School (post age-13)
Jewish Day School
Yeshiva High School
If you attended afternoon Hebrew School, how many years did you attend?
What was the Jewish Affiliation of your
Please Select
Reform
Conservative
Orthodox
Unaffiliated
If you attended Day School, how many years
What was the Jewish Affiliation of your
Please Select
Reform
Conservative
Orthodox
Unaffiliated
* Your Current Jewish Affiliation:
Please Select
Reform
Conservative
Orthodox
Unaffiliated
Other
* How would you describe your Hebrew speaking skills?
Please Select
None
Introductory
Intermediate
Fluent
Other
* How would you describe your Hebrew reading skills?
Please Select
None
Introductory
Intermediate
Fluent
Other
* Do you hold any leadership/professional positions in Jewish organizations?
Please Select
Yes
No
Position:
* Have you been to Israel before?
Please Select
Yes
No
In What Context?
* What types of Jewish experiences
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 number:
Best time to reach him/her:
Email:
Reference 2
Name:
Relationship:
Address:
Phone Number:
Best time to reach
him/her:
Email:
Special
Requirements
*
Do you have any accessibility
requirements or physical limitations or restrictions?
Please
Select Yes No
If so, please
elaborate:
*
Do you have any special
dietary requirements?
Please Select Yes No
If so, please elaborate:
*
Are you currently taking any
medication?
Please Select Yes No
If so, please
elaborate:
*
Have you ever been
hospitalized?
Please
Select Yes No
If so, please
elaborate:
Personal Statement
* Please state your reasons
* How did you hear about the program?:
* Essay:
An interview is required for all qualified applicants . Following acceptance, the full amount for the program will be due, and will be non-refundable, due to the heavily subsidized nature of the trip.
I, the participant, give JAAM permission to charge my credit card on file to reimburse JAAM for this pro-rated amount should I neglect to participate in the program after my arrival in Israel.
Also, by submitting this application you are certifying that everything you have filled out is true to the best of your knowledge:
