Yeshivacation Registration Form Please fill out the form carefully as it enables us to design a program of study tailored to each individual student’s needs and requests. * Please have the following prepared: A recent digital photograph of yourself; Conversion papers (if relevant), and the Payment. ** Upon receipt of the completed application, an in-person or phone interview will be scheduled. At the interview, students will receive further information regarding classes, housing, and, if needed, financial aid.I. Personal InformationWhich session are you registering for?*WinterSummer July programSummer August programName* First Last Hebrew NameAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email* Enter Email Confirm Email Date of Birth* MM DD YYYYEmergency Contact Name* First Last Emergency Contact PhoneEmergency Contact RelationshipRelationship of Emergency Contact to youHighest Grade Completed*Some High SchoolHigh SchoolSome CollegeCertificateCollegeCollegeCollegeSeminaryProfessional TrainingCurrent OccupationWhat is your primary language?What other languages do you speak?II. General InformationWhy are you interested in learning at Yeshivacation?What are you hoping to gain from this program?Please tell us any additional information you think we should know about you.III. Jewish BackgroundAre you Jewish?*FatherMotherBothNoneAdoptedAre you a convert to Judaism?NoYesIf yes, who was the converting Beth Din?What is your most positive Jewish experience?What is your most negative Jewish experience?What is your general view of the Lubavitch movement?Jewish Contact/Referral #1 First Last Rabbi, Shliach, or a head of a Jewish organization that knows you wellJewish Contact/Referral #1 PhoneJewish Contact/Referral #1 Email Jewish Contact/Referral #1 Relationship to youJewish Contact/Referral #2 Name First Last Rabbi, Shliach, or a head of a Jewish organization that knows you wellJewish Contact/Referral #2 PhoneJewish Contact/Referral #2 Email Jewish Contact/Referral #1 Relationship to youUpload a recent photo of yourself*(jpg, gif, png)Permission to be included in pictures and videos for promotional purposes.*I agreeI don't agreeJoin our Email/Newsletter Email NewsletterWinter Yeshivacation Total:*Enter $770 or another approved amount if you applied for scholarship.
