To apply - print out this form, complete it, and mail with all application materials to the address at bottom by February 15th, 2006.
Name: ________________________________________________________
Address: ______________________________________________________
_____________________________________________________________
Telephone Number: ____________________________________________
Email Address: ________________________________________________
Social Security Number: _________________________________________
* Canadian residents please include your Social Insurance Number
Date of Birth: __________________________
Father's name: _________________________________________
Occupation: ____________________________________________
Employer: _____________________________________________
Mother's name: ________________________________________________
Occupation: __________________________________________________
Employer: _____________________________________________________
Name, Address and Telephone Number of your current school:
_______________________________________________________________
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Name of principal or guidance counselor:
_______________________________________________________________
Please list any awards or honors:
________________________________________________________________
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Name and age of brothers and sisters and schools they attend:
________________________________________________________________
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Name and address of your synagogue and its Rabbi:
________________________________________________________________
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Have you been to Israel? ______ Yes ______ No
If your answer was yes, please indicate the date(s) of your visit(s) and whether it was with your family or on a group tour. Which group?
_________________________________________________________________
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Do you belong to a Jewish youth group(s)? _____ Yes _____ No
If yes, please indicate the name(s) of such groups and what office(s) you held and whether you received any honors or awards.
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Do you do any volunteer work? ____ Yes ____ No
If your answer was yes, identify the organization(s) and briefly describe the work you do.
___________________________________________________________________
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Name and address of the school or program you plan to attend in Israel:
___________________________________________________________________
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Have you been accepted? ____ Yes ____ No
(Not a pre-requisite for this application)
Name of your local Jewish newspaper:
_____________________________________________________________
PART TWO
ESSAY: Write an essay of no more than two pages on the importance of studying Judaism in Israel and what you expect to gain from this experience.
PHOTOGRAPH: Please send a recent photograph of yourself.
RECOMMENDATIONS: Three recommendation forms must be submitted by February 15th, 2006. Please print out three recommendation forms (available by clicking here). Obtain one recommendation from your Rabbi, one from your principal, rebbe or teacher, and one from a person not related to you (if your rabbi is your father, ask someone else who is in a position to know you to write the recommendation). Please put your name and social security number on the form. The completed forms should be returned directly to the Scholarship Fund (not to you). You may give them a stamped envelope with the form. It is your obligation to make sure the forms are submitted on time.
Only typewritten or word processed materials will be accepted.
MAIL ALL MATERIALS TO:
Dr. Wallace Greene
Alisa Flatow Memorial Scholarship Fund
Post Office Box 4237
River Edge, NJ 07661-4237