Pathways Students - Application Form

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Registration for Pathways Israel 2010

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 Name    
   
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   
If 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. Please list activities and organizations in which you have participated. In what capacity did you participate?

24. Hobbies, including artistic skills


Jewish Background

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

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)
Current Jewish Involvement
31. Do you regularly attend Jewish events on campus or near your workplace?
Yes No
If yes, what kinds of events?
How often?
 
32. Do you regularly learn with a local or campus rabbi or other educator?
Yes No
If yes, with whom?

How long have you been learning together?
How regularly do you learn?
 
33. Please describe your current level of observance.

Special Requirements

34. Do you have any medical conditions or physical disabilities?
Yes No
Please describe
35. Are you currently taking any medication?
Yes No
Please specify
36. Do you have any special dietary requirements?
Yes No
Please specify

Emergency Contact Details

37. In case of emergency, please contact
a. In Israel
Name Phone Relationship
Address
b. In Native Country
Name Phone Relationship
Address

Credit Card Details

38. Card Type Name of Cardholder Card Number Expiry Date

References

39. Reference 1
Name Phone E-mail address Relationship
Address
40. Reference 2
Name Phone E-mail address Relationship
Address
41. 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
42. If you were not recommended to come on PATHWAYS by a Rabbi or Jewish educator, how did you hear about the program?

Personal Statement

43. 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 2, 4, and 1 to have this form submitted.
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