Application

APPLICATION FORM 5784

צעירי השלוחים
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Hebrew D. O. B.*
Nationality*
Please list all passports
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recent picture*

Cancelof
Cheider*
Teacher*
Has your son applied for Yeshiva Ketana*
Which*
Have any of his close חברים applied to YK Prague as well?*

YesNo
Please specify*

Passport copy

Cancelof
Email for communication*
example@example.com

Parents Marital Status*
Fathers Name*

First NameLast Name
Fathers Phone Number*
Occupation*
Mothers Name*

First NameLast NameMaiden Name
Mothers Phone Number*
Occupation*

Does your son have any medical/dietary conditions?*

YesNo
Please specify*
Has your son sustained any serious injury?*

YesNo
Details, year & treatment*
Any other medical conditions that we should be aware of?*

I would like to register my son for*

The full program: ה' תמוז - י"ז אב - July 11 - August 211 month: ה' תמוז - ג' אב - July 11 - August 7
The cost for the full program is $3600, excluding airfare and mandatory health insurance.*

I am happy to pay the full tuition cost.I would like to request a Shluchim scholarship (up to $800). Limited availability.
The cost for the 1 month program is $3000, excluding airfare and mandatory health insurance.*

I am happy to pay the full tuition cost.I would like to request a Shluchim scholarship (up to $800). Limited availability.
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