Registration for Pathways Israel 2011 Couples Program Please fill out a separate application for each member of the couple. Eligibility Pathways Couples Program is open to married couples ages 20 to 29. No background in Jewish studies or Hebrew skills is necessary. Application If you are interested in joining the Pathways Couples Program please fill in the following on-line Application Form. Program Details 1. Program Dates Choose a program dates to be announced General Information 2. Last Name First Name Middle Name Hebrew 3. Birth Date (day/month/year) Place Of Birth Citizenship 4. Passport No Expires Social Security No 5. Gender Male Female 6. Marital Status Single Married Contact Information 7. Current Address Street and Number City State Zip Tel # Cell # E-mail address 8. Permanent Address (if not as current address) Street and Number City State Zip Tel # Cell # E-mail address Family Background 9. 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) 10. Father's Occupation Name of Business Address and Telephone Number 11. Mother's Occupation Name of Business Address and Telephone Number 12. Parents’ Jewish Affiliation Please select Conservative Orthodox Reform Other Unaffiliated 13. Are there any conversions or adoptions in your family history? Yes NoIf yes, please provide details Educational Background 14. What year are you in your college education? Please select Freshman Sophomore Junior Senior Completed college education Other Please specify if other 15. Colleges or Universities Attended Name of School Location Dates Degree Major & Minor 16. Which school are you currently attending? 17. If different, which school do you intend to travel with? 18. What are your vocational goals? 19. 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) 20. Activities and organizations in which you have participated, and in what capacity 21. Hobbies, including artistic skills Jewish Background 22. Jewish Education (if any) Name of School Location Dates Curriculum Proficiency 23. Your Jewish Affiliation Please select Conservative Orthodox Reform Other Unaffiliated 24. My knowledge of Hebrew is Reading Please select Good Fair Poor Writing Please select Good Fair Poor Speaking Please select Good Fair Poor Understanding Please select Good Fair Poor 25. Do you hold any leadership/professional positions in Jewish organizations? Yes No If yes, please provide details 26. Have you been to Israel before? Yes No If so, with whom (please list all previous trips to Israel) 27. What other types of Jewish experiences have you had? (Bar/Bat Mitzva, youth group, fraternity, sorority) Special Requirements 28. Do you have any medical conditions or physical disabilities? Yes No Please describe 29. Are you currently taking any medication? Yes No Please specify 30. Do you have any special dietary requirements? Yes No Please specify Emergency Contact Details 31. In case of emergency, please contact a. In Israel Name Phone Relationship Address b. In Native Country Name Phone Relationship Address Credit Card Details 32. Card Type Name of Cardholder Card Number Expiry Date References 33. Reference 1 Name Phone E-mail address Relationship Address 34. Reference 2 Name Phone E-mail address Relationship Address 35. 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 36. If you were not recommended to come on PATHWAYS by a Rabbi or Jewish educator, how did you hear about the program? Personal Statement 37. 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. For security reasons, please check 8, 7, and 2 to have this form submitted.1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
