Chai Israel 2025-2026
Teen High School & Gap Year Scholarship Form
Please complete this form so we can see your eligibility for the various community offerings.
Student Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Student Phone Number
*
-
Area Code
Phone Number
Student Email
*
example@example.com
Parent 1 Name
*
First Name
Last Name
Parent 1 Email
*
example@example.com
Parent 2 Name
First Name
Last Name
Parent 2 Email
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Israel Program Attending (Specific name)
*
Program Start Date
*
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Month
-
Day
Year
Date
Program End Date
*
-
Month
-
Day
Year
Date
Program Website
*
Published cost of program (after RootOne grant if applicable)
*
Please upload a copy of your program acceptance letter
*
Browse Files
Cancel
of
Synagogue Affiliation, if any
Are you in a Hebrew High program?
Yes
No
Have you signed a Teen Israel agreement?
Yes
No
I don't know
Are you an active member of a Jewish youth group?
Yes
No
Which one(s) and what's the nature of your involvement (local or regional board)?
Do/did you attend a day or overnight Jewish camp?
Yes
No
If yes, which one(s) and how many summers?
Do/did you attend a Jewish day school?
Yes
No
Which one(s) and for what grade(s)?
Any other Jewish activities you were/are involved with in Middle School/High School (e.g. OJCYF, one on one learning, etc.)?
Submit
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