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Jewish Experience Week Med Connections
First Name: *
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Last Name: *
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Gender *
Date of Birth *
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Permanent Home Address:
Street Adress: *
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City, State, ZIP: *
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Cell: *
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Email: *
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Parents Information:
Mother's Name: *
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Mother's Contact #: *
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Is your mother Jewish? *
If yes,
Father's Name: *
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Father's Contact #: *
Your answer
Is your father Jewish *
If yes,
Are these your birth parents? *
If no, please explain:
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Getting to Know You:
What is your Campus and Major? *
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How would you describe your Jewish background and affiliation? Please Explain *
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Please list Maimonides programs,Israel trips or other programs that you've attended: *
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Please list your Rabbi(s) and their contact info: *
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Do you take any medications or have any medical conditions? *
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Do you have any food allergies or dietary needs?
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In two paragraphs, please explain what you hope to gain from the Jewish Experience Week- Med Connections program: *
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All personal information will be held in strict confidence.

I affirm that all the information provided in this application is true, and understand the Jewish experience week guidelines enumerated below:

1) I will comply with all basic standards of program conduct in a manner befitting a Jewish Experience Week Ambassador. Jewish Experience Week reserves the right to ask any fellow to discontinue participation for inappropriate behavior, not following the schedule or for any reason the staff see's fit.. In such event the student will forfeit his deposit and internship.

2) A personal interview will be required before final admission.

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