REGISTRATION FOR PATHWAYS Summer 2008

ELIGIBILITY

Pathways is open to single men and women aged 19 to 29.

No background in Jewish studies or Hebrew skills is necessary.

With few exceptions, all participants will be college students and young professionals.

APPLICATION

If you are interested in joining the Pathways Program please fill in the following on-line Application Form.

PROGRAM DETAILS

1. Program Dates

2. School with which you intend to travel

GENERAL INFORMATION

3. Last Name	First Name	Middle Name	Hebrew

4. Birth Date (day/month/year)	Place Of Birth	Citizenship

5. Passport No	Expires	Social Security No

6. Gender Male Female

7. Marital Status Single Married

CONTACT INFORMATION

8. Current Address
Street and Number		City	State

Zip	Tel #	Cell #	E-mail address

9. Permanent Address (if not as current address)
Street and Number		City	State

Zip	Tel #	Cell #	E-mail address

10. Father's Address

Home phone	E-mail address

11. Mother's Address (if not the same as father’s)

Home phone	E-mail address

FAMILY BACKGROUND

12. a) Parents' Marital Status
Married Divorced/Separated Deceased
Which Parent?
b) Father's Name	Place of Birth

c) Mother's First & Maiden Name	Place of Birth

d) Mother’s Last Name (if not the same as father’s)

13. Father's Occupation	Name of Business

Address and Telephone Number

14. Mother's Occupation	Name of Business

Address and Telephone Number

15. Parents’ Jewish Affiliation

16. Are there any conversions or adoptions in your family history?
     Yes  No
     If yes, please provide details

EDUCATIONAL BACKGROUND

17. What year are you in your college education?

     Please specify if other

18. Colleges or Universities Attended
Name of School	Location	Dates	Degree	Major & Minor

19. Which school are you currently attending?

20. If different, which school do you intend to travel with?

21. What are your vocational goals?

22.	If time has elapsed since you last attended school, describe how that time has been spent? (If you have been employed please give name of company or employer)

23.	Activities and organizations in which you have participated, and in what capacity

24. Hobbies, including artistic skills

JEWISH BACKGROUND

25. Jewish Education (if any)
Name of School	Location	Dates	Curriculum	Proficiency

26. Your Jewish Affiliation

27. My knowledge of Hebrew is

Reading		Writing
Speaking		Understanding

28.	Do you hold any leadership/professional positions in Jewish organizations?
Yes No
If yes, please provide details

29. Have you been to Israel before?

Yes No

If so, with whom (please list all previous trips to Israel)

30.	What other types of Jewish experiences have you had? (Bar/Bat Mitzva, youth group, fraternity, sorority)

SPECIAL REQUIREMENTS

31. Do you have any medical conditions or physical disabilities?

Yes No

Please describe

32. Are you currently taking any medication?

Yes No

Please specify

33. Do you have any special dietary requirements?

Yes No

Please specify

EMERGENCY CONTACT DETAILS

34. In case of emergency, please contact
a. In Israel
Name	Phone	Relationship

Address

b. In Native Country
Name	Phone	Relationship

Address

CREDIT CARD DETAILS

35. Card Type	Name of Cardholder	Card Number	Expiry Date

REFERENCES

36. Reference 1
Name	Phone	E-mail address	Relationship

Address

37. Reference 2
Name	Phone	E-mail address	Relationship

Address

38.	If you were recommended to come on PATHWAYS by a Rabbi or Jewish educator, on campus or otherwise, please provide details.
	a. Name of Rabbi/Teacher	b. Campus

	c. Phone	d. E-mail address

39.	If you were not recommended to come on PATHWAYS by a Rabbi or Jewish educator, how did you hear about the program?

PERSONAL STATEMENT

40.

Please write a short (100 word) essay giving your reasons for wanting to come to Israel and be part of the Pathways Israel Program

I agree to abide by the rules and regulations set by PATHWAYS for the health, safety and welfare of the students.

I understand that PATHWAYS and Darché Noam/Shapell’s, while they will take precautions to eliminate the risk of loss or damage to my personal property, are not held financially responsible if such loss or damage should occur.

I understand that the PATHWAYS program is subject to change or cancellation at any time.

Following acceptance, the full amount for the program will be due, and will be non-refundable, due to the heavily subsidized nature of the trip. Students agree to participate fully in all events and activities on the schedule in order to receive the scholarship. A working copy of the schedule will be available in advance for your review. Failure to fully participate in the program on arrival in Israel may result in the participant forfeiting his or her subsidy for that day, based on the program's true value (approximately $2,500.00 total). I, the participant, give Pathways permission to charge my credit card on file to reimburse Pathways for this pro-rated amount should I neglect to participate in the program after my arrival in Israel.
I certify that the information given in this application is complete and correct. Misrepresentations could result in the applicant being responsible for the value of his or her scholarship awarded on the basis of false information.