Resident Application

To apply for Machon Chana programs, please fill out this four part form. Thank you! After filling this Application form, please call 347- 200- 0632 between 11 am till 3 pm (NY time) to schedule an interview (if you are not able to participate in a face to face interview, a skype interview can be set up).

"*" indicates required fields

Step 1 of 6

I. Personal Background

Program Applying for*

Arrival Date*

When would you like to begin your studies? (could be approximate date)

Title

Name*

First Last

Hebrew Name*

Please enter "no" if you don't have

Marital Status*

Maiden Name

Current Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone*

Mobile Phone*

Email*

Enter Email Confirm Email

Country of Citizenship*

Social Security/ Passport Number*

Age*

Date of Birth*

Place of Birth*

City

State / Province

Country

Permanent Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Is there anyone else living at this address?*

Name

Relation to you

Occupation*

Studying

Studying and working

Working

Other

Employer Phone Number*

Employer Name*

First Last

Father/ Legal Guardian Name*

First Last

His Hebrew Name*

Please enter "no" if he doesn't have

Father's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Please enter the address if different than yours

His Phone Number*

His Email*

Mother/ Legal Guardian Name*

First Last

Her Hebrew Name*

First Last

Please enter "no" if she doesn't have

Mother's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Please enter the address if different than yours

Her Phone Number*

Her Email*

Was your mother born Jewish?*

Please upload your mother's or your conversion papers*

Max. file size: 32 MB.

Please upload your recent picture*

Max. file size: 32 MB.

References

Please submit two references, including a rabbi or rebbetzin and, preferably, a Jewish community/ campus leader or someone who knows you well. Please list the people who will be submitting references on your behalf and DETAILED letters of recommendation written on the business or personal letterhead of the person submitting the letter.

First Jewish Contact/ Reference*

Name

Relation to you

Phone Number

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Upload First Reference

Max. file size: 32 MB.

Second Jewish Contact/ Reference*

Name

Relation to you

Phone Number

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Upload Second Reference

Max. file size: 32 MB.

Application Objective

How long do you plan to attend Machon Chana?*

One term

One year

Two years

Summer (yeshivacation)

Winter Break (yeshivacation)

Other

Why do you want to learn at Machon Chana, and what are your goals for attending the school?*

Will you need accommodations while studying at Machon Chana?*

Yes

Other

Please explain why*

How or from whom did you hear about Machon Chana?*

IV. Medical Form

All information will remain strictly confidential and will only be used by medical providers in case of medical necessity while the student is in school. Students with pre-existing health conditions must have medical insurance/coverage or proof of ability to pay for any necessary medical treatment and medication. If there is a medical condition that affects one’s attendance of classes, she will need to return home to care for her health. By signing this form you agree to pay for any costs associated with health care that may not be covered by your insurance should the staff determine you are in need of such.

Name of Student*

First Last

Date of Birth*

In case of emergency contact:*

Name

Relation to you

Emergency Contact Phone Number*

Emergency Contact Address*

Street Address City State / Province / Region ZIP / Postal Code Country

1. Do you have any special dietary requirements?*

If yes, Please provide details

2. Do you now or have you ever suffered from an eating disorder?*

If yes, Please provide details

3. Have you ever received psychological counseling?*

If yes, Please provide details

4. Do you suffer from any mental or emotional illnesses?*

If yes, Please provide details

5. Do you suffer from any allergies?*

If yes, Please provide details

6. Do you suffer from asthma, eczema or hives?*

If yes, Please provide details

7. Do you suffer from any of the following?*

Tuberculosis

Epilepsy

Heart diseases

Respiratory illnesses

Diabetes

Digestive tract diseases (such as chronic constipation or diarrhea)

Any other significant illness

None

If yes, Please provide details

8. Did you have any hospitalizations and surgeries in the past?*

If yes, Please provide details

Month/Year

Length of Hospitalization

Diagnosis

9. Do you have any physical limitations?*

If yes, Please provide details

10. Do you take any medication(s)?*

If yes, Please list name of medication(s) and reason for use

11. Are you allergic to any medication(s)?*

If yes, Please provide details

Is it there any other information regarding your health which you feel we should know about?

I have read the above and affirm that all information contained on this application is true and accurate to the best of my knowledge. Falsifying or purposefully leaving out any information on this medical form is cause for immediate expulsion from the school and dorm, as well as cancellation of the student visa in case of foreign students. If there is medical information that a prospective student deems extremely confidential and does not wish to write on this for it must be discussed orally with Mrs Labkowski.

Signature

Applicant's Signature*

Please re-enter your full name

Date*

Parent/ Guardian Signature

(If applicant is under 18 years of age)

Resident Application