Form

LEGACY ISRAEL WOMEN'S TRIP 2010.

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 of any address or phone number changes at 514 604 2229. ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL
General information
First Name*
Last Name*
Birth Date*
Month Day Year
How Did You Hear About the Trip?
Please enter the name of the referring individual or organization, if applicable:*
Citizenship*
Passport Number*
Passport Expiration Date (dd/mm/yy)*
Name of CGEP or University that you are currently attending*
If other, please specify
Year of Graduation*
Current Employer (Mandatory if graduated)
Job Title (Mandatory if graduated)
Contact Information

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone Number*
- Area Code Phone Number
Alternate Phone Number*
- Area Code Phone Number
E-mail*
Permanent Home Address / Parents Home Address
Residence of*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
Family Background
Mother's Full Name*
First Name Last Name
Mother's Occupation
Father's Full Name*
First Name Last Name
Father's Ocucpation
Parents' Marital Status
Was Your Father Born Jewish?*

Yes No
Please Summarize Any Conversion History if Neccesary
Was your Mother Born Jewish?*

Yes No
Please Summarize Any Conversion History if Neccesary
Were All of Your Biological Grandparents Born Jewish?*

Yes No
If No, Please Explain
Parents' Jewish Affiliation*
Educational History
How Many Years of Education Have you Completed? (starting with first grade)*
What extracurricular activities, hobbies and organizations are you involved in? Please describe your participation and position in these activities:*
Jewish Education
What Jewish Education Have You Had?*
If you Attended Hebrew/Sunday School, How Many Years Did You Attend?
If you attended Day School, how many years did you attend?
What was the Jewish Affiliation of your Hebrew 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?*
If Yes, What Position Did You Hold?
Have you been to Israel before?*

Yes No
In What Context? (Bat Mitzvah, Year abroad, March of the Living, birthright israel, Yeshiva study, etc.*
Have you been on a Jewish Experience Trip before?(Jerusalem or Sephardic Fellowships/Return n' Learn- Jewel)*

Yes No
If Yes, What Trip and When? (i.e. Sephardic Fellowships, 2009)
What types of Jewish experiences have you had? (Bat Mitzvah, youth group, fraternity/sorority, etc)*
My top 4 life priorities are:*
Survey
Are you a practicing Jew?*

Yes No
Compared to others, Jewish causes are:*
Desire to be Close to the Jewish People?*
Has JEP or Jewish Experience contributed to your growth in Judaism?*

Yes No
Is it important for you to marry Jewish?
How do you identify yourself?*
How is Torah relevant to you?*
Do you intend to extend your stay in Israel?*

Yes No Maybe
If yes, for how long?
Please recommend a friend who you think would be interested in this trip
Full Name*
First Name Last Name
Phone Number
- Area Code Phone Number
E-mail
Special Requirements
Do you have any accessibility requirements or physical limitations or restrictions*

Yes No
If Yes, please specify
Do you have any special dietary requirements?*

Yes No
If Yes, please specify
Are you currently receiving medical treatment or psychological counseling?*

Yes No
If Yes, Please Elaborate
Are you currently taking any medication?*

Yes No
If Yes, Please Elaborate
References

May not be a relative
First Reference Full Name*
First Name Last Name
E-mail*
Phone Number*
- Area Code Phone Number
Relationship to you*
Second Reference Full Name*
First Name Last Name
E-mail
Phone Number
- Area Code Phone Number
Relationship to you*
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. Also, owing to this fact, students agree to participate fully in all events and activities on the schedule in order to receive the scholarship. A working copy of the schedule will be available in advance for your review. Failure to fully participate in the program on arrival in Israel may result in the participant forfeiting her subsidy for that day, based on the program's true value. I, the participant, give Legacy Israel permission to charge my credit card on file to reimburse Legacy Israel 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. Full and honest reporting is essential for effective review by the Legacy Israel application review board and misrepresentations could result in the applicant being responsible for the value of his or her scholarship awarded on the basis of false information. Please note, a $150 damage deposit fee will be collected at the beginning of the trip. The full amount will be returned to you at the conclusion of the trip, barring the need to deposit it due to damages caused by you, the participant. Please note:Students with preexisting health conditions MUST purchase travel insurance prior to departure.
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LEGACY ISRAEL WOMEN'S TRIP 2010.

General information

Contact Information

Permanent Home Address / Parents Home Address

Family Background

Educational History

Jewish Education

Survey

Please recommend a friend who you think would be interested in this trip

Special Requirements

References