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FIRST NAME

LAST NAME

DATE OF BIRTH

COUNTRY OF BIRTH

GENDER
MaleFemale

ADDRESS

PHONE

MARITAL STATUS

MOTHER'S NAME

FATHER'S NAME

JEWISH AFFILIATION

MOTHER BORN JEWISH?
YesNo

FATHER BORN JEWISH?
YesNo

ARE YOU A CONVERT TO JUDAISM?
YesNo

ARE YOU A FULL-TIME STUDENT?
YesNo

HIGH SCHOOL ATTENDED

YEAR OF GRADUATION

COLLEGE ATTENDED

COLLEGE MAJOR

YEAR OF GRADUATION

EMPLOYMENT STATUS

EMPLOYMENT POSITION

EMPLOYER NAME

EMPLOYER ADDRESS

WHICH JEWISH EDUCATIONAL PROGRAMS HAVE YOU PARTICIPATED IN BEFORE? (IF ANY)

HAVE YOU PARTICIPATED IN A BIRTHRIGHT TRIP TO ISRAEL?
YesNo

HAVE YOU PARTICIPATED IN ANY JEWISH EDUCATIONAL TRIPS (OTHER THEN BIRTHRIGHT)?
YesNo

DO YOU KNOW HOW TO READ HEBREW?
YesNo

HAVE YOU EVER ATTENDED A JEWISH SCHOOL?
YesNo

HOW MANY YEARS DID YOU ATTEND?

WHICH GRADES?

LIST ANY GROUPS, CLUBS, OR FRATERNITIES/SORORITIES YOU BELONG TO

HOW DID YOU HEAR ABOUT THE PROGRAM?

BRIEFLY EXPLAIN WHAT YOU HOPE TO GAIN FROM THE LA JEWISH EXPERIENCE - ISRAEL TRIP