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Sample Itinerary
Application
Due to COVID19 concerns, our summer 2020 trip has been postponed, but feel free to submit your information to be contacted for our next trip.
Application for the Israel ReCharge Trip
:
Summer 2020
Please fill in all the required information (as denoted by
*
), otherwise your application will not be accepted.
After successfully submitting this application you will receive a confirmation message.
Please notify us of any address or phone number changes at
seisenberg93@gmail.com
or call 917-945-7342
*
Indicates required field
Program Dates
*
The Israel Recharge Trip: July 1– July 13, 2020
General Information
Name as it appears on your passport (including middle if applicable)
*
First
Last
Put first and middle name in the field titled "First "
Gender
*
Male
Female
Upload a recent photo of yourself
*
Max file size: 20MB
Full Name as you would like it to appear on a name tag
*
FaceBook Name
*
Passport No
*
Country of Citizenship
*
Date of Birth (mm/dd/yyyy)
*
How did you hear about the Program?
*
School Information
Year of Graduation
*
2012
2013
2014
2015
2016
2017
2018
2019
2020
College Grad
Graduate School
Graduate School Grad
Other
University/College
*
Major
*
Employment Information
Current Employer
*
If full time student, write STUDENT
Job Title
*
What extracurricular activities, hobbies and organizations are you involved in? Please describe your participation in them.
*
Your Contact Information
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Cell/Work Number
*
Email
*
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Full Name of Spouse
*
If you are married, is your spouse applying as well?
*
Yes
No
N/A
Permanent/Parents' Home Address
Residence of:
*
Self
Parents
Mother
Father
Parent(s) Phone Number
*
Name of Emergency Contact
*
Emergency Contact Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Family Background
Mother's Name
*
First
Last
Mother's Occupation
*
Father's Name
*
First
Last
Father's Occupation
*
Parents' Marital Status
*
Married
Father Deceased
Mother Deceased
Divorced/Separated
Parents Jewish affiliation
*
Conservative
Reform
Orthodox
Unaffiliated
Other
Was your father born Jewish?
*
Yes
No
Please summarize Father's conversion history if any
*
Was your mother born Jewish?
*
Yes
No
Please summarize Mother's conversion history if any
*
Were all your grandparents born Jewish?
*
Yes
No
If no, please summarize the conversion history of any grandparents who converted. Please indicate if they were paternal or maternal.
*
Jewish Background
What Jewish Education have you had?
*
Virtually None
Hebrew School/Sunday School (until age 13)
Hebrew School/Sunday School (past age 13)
Jewish Day School
Yeshiva High School
If you attended afternoon Hebrew School, how many years did you attend?
*
What was the Jewish Affiliation of your Hebrew School?
*
Reform
Conservative
Orthodox
Unaffiliated
If you attended Day School, how many years did you attend?
*
What was the Jewish Affiliation of your Day School?
*
Reform
Conservative
Orthodox
Unaffiliated
Your Current Jewish Affiliation:
*
Reform
Conservative
Orthodox
Unaffiliated
Other
How would you describe your Jewish education?
*
Insufficient
Complete
Other
If you specified "Other" Please expain
*
How would you describe your Hebrew speaking skills?
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Introductory
Intermediate
Fluent
Other
How would you describe your Hebrew reading skills?
*
Introductory
Intermediate
Fluent
Other
Do you hold any leadership/professional positions in Jewish organizations? If yes, what position?
*
What types of Jewish experiences have you had? (Bar Mitzvah, youth group, fraternity/sorority, etc)
*
Have you been to Israel before?
*
Yes
No
In What Context? (Bar/Bat Mitzvah, Year abroad, March of the Living, birthright israel, Yeshiva study, etc.)
*
If you were on a birthright trip, please indicate which one.
*
My top 4 life priorities are:
Priority 1:
*
Priority 2:
*
Priority 3:
*
Priority 4:
*
Special Requirements
Do you have any accessibility requirements or physical limitations or restrictions?
*
Yes
No
Accessibility Details, if any:
*
Do you have any special dietary requirements?
*
Yes
No
Dietary Details, if any:
*
Are you currently receiving medical treatment or psychological counseling?
*
Yes
No
Treatment Details, if any:
*
Are you currently taking any medication?
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Yes
No
Medication Details, if any:
*
Have you ever been hospitalized?
*
Yes
No
Hospitalization Details, if any:
*
The Last two questions!
With programs in over 30 countries, Olami and its funding partners sometimes use independent verification firms to assure that programs are attended and impactful. By registering, I understand that I might be contacted by a verification firm for quality control purposes.
*
I agree
Olami is funded in part by Mosaic United. Please let us know if you would like to be contacted regarding future Mosaic sponsored-opportunities.
*
Yes
No
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Sample Itinerary
Application
