APPLYING ON-LINE for the Aish LA MBA Leadership Mission to Israel: Winter 2008-09

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:
	Hebrew Name and Mother's' Hebrew Name:
*	Date of Birth:	(mm/dd/yyyy)
*	Passport No:	Exp. Date:
	Full Name on Passport:
*	Gender:
*	How did you hear about the Program?
	Please enter the name of the referring individual or organization, if applicable:
*	Country of Birth:

College Information

*	Year of Graduation :
*	University/College:
	Major:

Employment Information (Mandatory if graduated)
	Current Employer:
	Job Title:
	Dates of Employment:
	Previous Employer :
	Job Title:
	Dates of Employment:
	What are your career or educational plans for the next year? Include location if confirmed:

Your Contact Information

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

*	Your Marital Status:

Permanent/Parents' Home Address

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

Family Background
	Ethnicity:
	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?

(i.e. 1st - 12th grade, plus 2 yrs of college would = 14)

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 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)

	My top 4 life priorities are:
*	1.
*	2.
*	3.
*	4.

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
	Have you received psychological counseling in the past ?
	If so, please elaborate:
*	Are you currently taking any medication?
	If so, please elaborate.
*	Have you ever been hospitalized?
	If so, please elaborate.

Scholarship Information
The cost of the mission is $3,600; the maximum scholarship amount is $3,000. Scholarship assistance is limited and is granted at the discretion of the Aish LA scholarship committee. Please fill in the following information for the committee's evaluation:
*	Are you requesting a trip scholarship?
	If so, how much of a scholarship are you requesting and why? (Please state your annual income, total savings and investments, and total debt).

To be considered for a scholarship, you must fill out the following information:
	Annual Income:
	Total Savings and Investments:
	Total Debt:

Personal Statement
*	Please state your reasons for wanting to attend the Aish LA Israel Adventure (brief explanation).

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?:
*	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:

An interview will be scheduled for all qualified applicants. Following acceptance, a deposit of $300 is due to secure your spot and is refundable up until November 5th. Payment in full is due on November 19th and any balance will be automatically charged to your credit card unless you specify otherwise in advance of November 19th. The balance becomes nonrefundable at that time. This program is heavily subsidized. Participants agree to participate fully in all events and activities on the schedule to receive the scholarship. A working copy of the schedule is available in advance for your review. Failure to attend the program once arriving in Israel may result in the participant forfeiting his or her subsidy for that day (up to $250 per day, depending on subsidy award). By submitting this application, I, the participant, give Aish L.A. permission to charge my credit card on file to reimburse Aish for up to $250 per day if I neglect to participate on 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: