APPLYING ON-LINE for Aish 20s -- Spring 2005

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 jf@aish.com or call 1-845-425-8255 ext. 201

Program and Preferred Dates

Program Dates:

General Information

*	First Name:
*	Last Name:
*	Date of Birth:	(mm/dd/yyyy)
	Passport No:
*	Gender:
*	How did you hear about the Program?
	Please enter the name of the referring individual or organization, if applicable:
*	Country of Birth:

School Information

*	Year of Graduation:
*	University/College:

Employment Information (Mandatory if graduated)
	Current Employer:
	Job Title:

Your Contact Information

*	Address:
*	City:
*	State/Province:
*	Zip:
*	Country:
*	Phone Number:	(###-###-####)
*	Phone Number Cell/Work:	(###-###-####)
*	E-mail:
*	Your Marital Status:

Permanent/Parents' Home Address

*	Residence of:
*	Address:
*	City:
*	State/Province:
*	Zip:
*	Country:
*	Phone Number:	(###-###-####)
	Fax:	(###-###-####)
	E-mail:

Family Background
	Mother's First Name:
	Mother's Last Name
	Mother's Occupation
*	Father's First Name:
	Father's Last Name:
	Father's Occupation
	Parents' Marital Status:

*	Was your father born Jewish? Please summarize conversion history if any
*	Was your mother born Jewish? Please summarize conversion history if any:
*	Parents Jewish affiliation
*	Were all your grandparents born Jewish? If no, please explain.

Educational History

* How many years of education (starting with first grade) completed?

What extracurricular activities, hobbies and organizations are you involved in? Please describe your participation in them:



Jewish Background
*	What Jewish Education have you had?
	If you attended afternoon Hebrew School, how many years did you attend?
	What was the Jewish Affiliation of your Hebrew School?
	If you attended Day School, how many years did you attend?
	What was the Jewish Affiliation of your Day School?
*	Your Current Jewish Affiliation:
*	How would you describe your Jewish education?
	If you specified "Other" Please expain
*	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?
	Position:
*	Have you been to Israel before?
	In What Context? (Bar/Bat Mitzvah, Year abroad, March of the Living, birthright israel, Yeshiva study, etc.)
*	What types of Jewish experiences have you had? (Bar Mitzvah, youth group, fraternity/sorority, etc)

References
	(Please include name, address, phone, relationship to you and the best time of day he or she can be reached. Please do not include family or friends
*	Reference 1
	Name
	Relationship
	Address
	Phone number
	Best time to reach him/her
	Email
*	Reference 2
	Name
	Relationship
	Address
	Phone Number
	Best time to reach him/her
	Email

Special Requirements
*	Do you have any accessibility requirements or physical limitations or restrictions?
	If so, please elaborate.
*	Do you have any special dietary requirements?
	If so, please elaborate.
*	Are you currently receiving medical treatment or psychological counseling?
	If so, please elaborate
*	Are you currently taking any medication?
	If so, please elaborate.
*	Have you ever been hospitalized?
	If so, please elaborate.

Survey

*	Are you a practicing Jew:
*	Comp to others, Jewish causes are:
*	Desire to be close to Jewish people:
*	Has Aish attributed to your growth:
*	How do you identify yourself?: (Please Substitute "Canadian" for "American")
*	How is Torah relevant to you?:
*	How often do you help fellow Jews:
*	How often do you learn Torah?:
*	What is your attitude to marraige:
*	Will your children's education have: