Poland trip apply Poland trip application 1 Background Information2 Jewish Identity3 Personal Information Your Campus*Choose your campusAlbanyBrooklynBuffaloMontclairPenn StateUMBCUConnName* First Last Gender*FemaleMaleDate* Phone*Preferred Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country College*Date of Graduation* Do you plan to study abroad?*Do you plan to study abroad?YesNoMaybe Was your biological father born Jewish*Was your biological father born Jewish?YesNoFather's conversion historyWas your biological mother born Jewish*Was your biological mother born Jewish?YesNoMother's conversion historyWhat Jewish education have you had?What Jewish education have you had?Virtually NoneHebrew School / Sunday School (pre age - 13)Hebrew School / Sunday School (post age - 13)Jewish Day SchoolYeshiva High SchoolWhat is your Jewish affiliation?What is your Jewish affiliation?Just JewishReformConservativeOrthodoxUnaffiliatedRecently becoming observantOther systems explored or observingConvert to Judaism, OrthodoxConvert to Judaism, OtherOther Jewish experiencesHave you ever been on an organized Jewish trip?Have you ever been on an organized Jewish trip?YesNoIsrael trips Emergency InformationParent 1 NameParent 1 PhoneParent 2 NameParent 2 PhoneMedicationAre you currently taking any medication or have any allergies?YesNomedication descriptionMedical treatmentare you receiving any medical treatment or psychological counseling?YesNomedical treatment descriptionHope to gainTrip Dates*Please select a trip date12/19/16 - 12/26/161/2/17- 1/9/17How did you hear about the program?How did you hear about the program?No referalFellowshipsWebsiteAish ClassesEyaht AlumnaeOtherAish.comAish HaTorah branchBirthright Israel websiteFacebook AdCampus Student OrganizationEmailFriendRelativeFlyerNewspaper adPast participantSearch engineRecruiterUntitled First Choice Second Choice Third Choice
