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| Program Application |
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| Arrival to Mayanot: |
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| Departure from Mayanot: |
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| Personal Details |
| First Name |
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| Middle Name |
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| Last Name |
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| Hebrew Name |
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| Birth date |
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| Sex |
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| Passport number |
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| Social Security number |
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| Place of birth |
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| Citizenship |
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Occupation/profession
(or future
plans)
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| Father’s full name |
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| Mother’s full maiden name |
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| Father’s Hebrew name |
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| Mother’s Hebrew name |
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List special skills, awards, or interests:
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| Personal History |
| Are you Jewish? |
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| Which of your parents are Jewish? |
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| Were you adopted? |
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| Were you born Jewish? |
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| Did you convert to Judaism? |
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| If yes, which was the converting Beit Din? |
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| Was your mother adopted? |
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| Was your mother born Jewish? |
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| If no, did your mother convert to Judaism? |
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| If yes, which was the converting Beit Din? |
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| Was your maternal grandmother adopted? |
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| Was your maternal grandmother born Jewish? |
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| If no, did your maternal grandmother convert to Judaism? |
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| If yes, which was the converting Beit Din? |
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| Medical History |
| Do you have any dietary restrictions? (vegetarian, vegan, no red meat, no dairy, etc.) |
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| Do you have any history of eating or dietary disorders or currently exhibit any signs of either? |
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If yes, please explain:
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| Have you been hospitalized in the past? |
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If yes, please indicate below:
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| Have you ever received psychological treatment and/or counseling in the past? |
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If yes, please explain:
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| Are there any medical/emotional conditions you currently have or have had in the past? |
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Please list any medical/emotional conditions you
currently have or have had in the past:
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| Are you currently taking any medications? |
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If yes, please indicate below:
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Please list any restrictions on activities (swimming,
hiking, etc.):
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Is there anything else you feel we should know about
your health in order to provide you with the best experience possible?:
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| Contact details |
| Current Address |
Address:
Address 2:
City:
Zip/Postal Code:
Country :
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| Current Telephone |
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Permanent Address
Same as Current |
Address:
Address 2:
City:
Zip/Postal Code:
Country:
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| Permanent Telephone |
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| Permanent Fax |
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| E-mail |
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| Emergency contact in overseas |
Name:
Telephone: |
| Emergency contact in Israel |
Name:
Telephone: |
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| Past visits to Israel |
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| General education from high
school on: |
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| Jewish and Hebrew education
since childhood |
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Involved in Jewish youth groups or Jewish groups
on campus?
If yes, on what levels and in which positions:
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| Synagogue / Temple with which you affiliate |
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| Name of Synagogue or Temple Rabbi |
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| Please rate your Hebrew language skills. |
| Reading: |
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| Comprehension: |
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| Speaking: |
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Essays |
Describe your motivations for
applying to Mayanot. (Approximately 500 words)
Discuss your goals
at Mayanot and
how you intend to fulfill them. (Approximately 200/400 words)
How you hope
to contribute to the Jewish people after studying at Mayanot. (Approximately 200/400 words)
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| References |
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How
did you hear about this program?
If other, please specify: |
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