APPLYING ON-LINE for the Yameena Fellowships Trip to Israel: Summer 2013

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 info@youngjewishconservatives.org or call 1-845-425-8255 ext. 201

Program and Preferred Dates

Program Dates:

General Information

*	First Name and middle (if applicable) as appears on Passport:
*	Last Name (as appears on Passport):
*	Full Name as you would like it to appear on a name tag:
*	Date of Birth:	(mm/dd/yyyy)
	Passport No:	Exp. Date:
*	Gender:
*	How did you hear about the Program?
	Please enter the name of the referring individual or organization, if applicable:
*	Country of Citizenship:

College Information

*	Year of Graduation :
*	University/College:
	Major (If your University/College was not not listed above, please enter it here as well):

Employment Information (Mandatory if graduated)
	Current 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
	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.

Activism
	Please list your experiences with Conservative activism.

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.

Personal Statement

Please state your reasons for wanting to attend the Yameena Fellowships Trip to Israel (brief explanation), and then describe what you hope to gain out of this trip?