Application Form

Program you would like to apply for (Men's Winter, Women's Winter or Poland:

Personal Information

First Name

Last Name

Gender

Please Upload a profile picture of yourself (selfie will do)

Profile Picture

Hebrew Name

Date of Birth

Mobile Number

Email Address

Country of birth

Language spoken at home other than english

PERMANENT CONTACT INFORMATION

Resident of

Address

City

Home Phone

State/ Province

Family Background

Mother's Full Name

Mother's Day Phone

Mother's Occupation

Mother's Email

Father's Full Name

Father's Day Phone

Father's Occupation

Father's Email

Parent's Marital Status

Into which religion were you born?

Into what religion was your mother born?

Into what religion was your father born?

Into what religion were your maternal grand-parents born?

Into what religion were your paternal grand-parents born?

What religion do you currently associate yourself with?

Please provide details of any conversions in your family. (type “none” if not applicable)

General Education History

High School

Location of high school

Date

Degree or certificate awarded

College/University

Location

Date

Degree or certificate awarded

College/ University

Location

Date

Degree or certificate awarded

Present Occupation:

Name of Employer:

Brief Job Description

Jewish Education History

What Jewish schools (if any) did you attend?

School

Location

Dates

Degree or certificate awarded

School

Location

Date

Degree or certification awarded

What Jewish education have you had?

Describe your Jewish education

Hebrew reading proficiency?

Hebrew speaking proficiency?

Hebrew understanding proficiency?

Which activities and outreach organizations have you participated in?

Do you hold any leadership/professional positions in Jewish organizations?

How would you describe your Jewish affiliation?

How would you characterize your Jewish observance?

What is your attitude towards marriage?

Previous Israel Travel History

Have you ever been to Israel?

Yes No

Dates you were in Israel?

Reason for your visit?

Have you ever been on Birthright?

Attended any other organized Jewish trips?

Special and Medical Requirements

Do you have any dietary requirements? If so, elaborate

Please indicate any medication you are currently or have taken for all aspects of your health:

Have you ever been hospitalized? If so please elaborate:

Please list any mental health or other characteristics of your medical history that we should be aware of:

Do you have any accessibility requirements or physical limitations or restrictions?

Emergency Contact Name:

Emergency Contact Number

References

Please do not include family or friends

1. Reference

Name

Relationship

Contact

2. Reference

Name

Relationship

Contact

How did you hear about Heritage Retreats?

Please use the space below to write two paragraphs describing what you hope to offer and gain from the Heritage Retreats program

Waiver

By checking this box and electronically signing below, I acknowledge that I have read and agree to the terms and conditions of the Heritage Retreats Trip Waiver Agreement.

Agree

Click The PDF Below To Read Waiver

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Full Name Signature

Date Signed