LEGACY ISRAEL TRIP 2010

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

MonthDayYear
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

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
E-mail
Permanent Home Address / Parents Home Address
Residence of
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Family Background
Mother's Full Name

First NameLast Name
Mother's Occupation
Father's Full Name

First NameLast Name
Father's Ocucpation
Parents' Marital Status
Was Your Father Born Jewish?
Please Summarize Any Conversion History if Neccesary
Was your Mother Born Jewish?
Please Summarize Any Conversion History if Neccesary
Were All of Your Biological Grandparents Born Jewish?
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?
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)
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?
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?
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?
If yes, for how long?
Please recommend a friend who you think would be interested in this trip
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Special Requirements
Do you have any accessibility requirements or physical limitations or restrictions
If Yes, please specify
Do you have any special dietary requirements?
If Yes, please specify
Are you currently receiving medical treatment or psychological counseling?
If Yes, Please Elaborate
Are you currently taking any medication?
If Yes, Please Elaborate
References

May not be a relative
First Reference Full Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Relationship to you
Second Reference Full Name

First NameLast Name
E-mail
Phone Number

Area CodePhone 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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