I wish to attend classes from: until

Are you interested in attending the Sefardic Heritage program

Do you wish to live in our dorms and reserve a place? yes no

PERSONAL INFORMATION
Name of applicant:
Last
First
Hebrew

Current Address:
Street
City
State/Province Country
Postal code
Tel.: Fax: E-mail

Citizenship(s)

Passport number Expiration date (Passports should be valid for at least one year)

Israeli ID # (if relevant)

Permanent address (if different from above):
Street
City
State/Province Country
Postal code
Tel.: Fax:

Age
Date of birth: (Day/Month/Year) Place of birth

Father's Name: (first, last) Country of birth Date of birth
Occupation:

Mother's Name: (first, last, maiden) Country of birth Date of birth
Occupation

Parents marital status:
If parents have different addresses Please fill Mother's address first
Parent's Home address : Street City
Province/State Country
Postal code Parents home Tel

Father's street address City
Province/State Country
Postal code Home Tel

Were you born Jewish? yes  no

Was your Mother born Jewish yes no Was your Father born Jewish yes no

Were all your grandparents born Jewish yes no
If no, please elaborate

If you or your Mother converted to Judaism, please indicate Rabbi/Beit Din, location and date of conversion:
Please send a copy of any and all conversion documents.

Your Marital status: Single Married Divorced Widowed

If married please fill out the below
Husband’s name Place of work/study Position:

Citizenship(s) Passport number: Expires

Israel ID # (if relevant) Cell #

Synagogue: Synagogue Address: Synagogue tel
Rabbi's name Rabbi's E-mail (insert none if unavailable)
Tel.:

Do you keep kosher: at home? yes no     Outside the home? yes no

Do you describe yourself as Orthodox Conservative Reform Reconstructionist Non affiliated Other

  
Medical Information – for Information use only (this information will remain confidential)
Do you have any medical issues? yes no

they are:
Have you ever had surgery? If so, please elaborate
Are your activities limited yes no


if so, please elaborate
Do you have any specific dietary needs?
Do you suffer from allergies?
Are you currently taking any prescription medications? yes no
If so, please elaborate and include any prescribed medications .

Have you ever consulted or been treated by a Psychologist, Psychiatrist, Social Worker or Counselor? If yes, please elaborate, and include any medication that were prescribed

.

EDUCATION
Please list College/University, Name, Location, Years attended, Major, Degree.

Torah education

How well do you know Hebrew?

Reading ability Beginner fair good exellent
Translating ability Beginner fair good exellent
Rashi script reading Beginner fair good exellent
Knowledge of Halacha Beginner fair good exellent
Knowledge of Prayer (in Hebrew) Beginner fair good exellent

In order to best accommodate our students, please elaborate on any special learning difficulties you may have.

.

Vocational goals: (Describe briefly your career / professional goals)

Extra-Curricular Activities: (Describe briefly activities and organizations you have been actively involved in.)

Describe what you have done since leaving school if this is applicable.   

.

EMPLOYMENT
Employer: Dates of employment: Position held:

ISRAEL EXPERIENCE
Name of program/s in which I have participated: Dates attended:

RECOMMENDATIONS
Two letters of recommendation are required. They should be from people who know you well. At least one should be from a Rabbi or Torah educator who has known you for at least one year. Please list the details regarding those who are writing recommendations for you below:
Please send these letters to inquiry@shearim.com

1) Name:
Position Tel.:
E-mail: Address:

2) Name:
Position Tel.:
E-mail: Address:

Is there someone in Israel who can serve as a reference for you. yes no

If yes, please fill in the following:

Name:
Relationship to you :

Address:
Tel.: Cell:
E-mail:

.

IN CASE OF EMERGENCY, PLEASE CONTACT:
In Israel: Name: Address:
Tel. Cell:
Relationship

In native country:
Name
Address:
Tel. Cell

Who referred you to She’arim? List two people that we may contact:
Name:
Phone number:
E-mail:
Relationship to you:

Name
Phone number:
E-mail
Relationship to you:

.

PERSONAL STATEMENT
Please write an essay describing your personal attitudes and relationships to family members, your background in Judaism, your present commitment to Judaism, and your goals in attending She'arim. Please describe the extent of your present textual skills and knowledge in Jewish studies.

I agree to abide by all the rules, regulations and financial arrangements set by She'arim. I authorize She'arim to contact any individuals or organizations listed in this application. I understand that She'arim is not responsible for loss or damage of applicant's personal property. I grant She'arim permission to disperse or dispose of any personal property left by me upon my departure from the program.

Signature Date: