Application For Golden Leaves Institute
2016 Application
Email address *
First Name *
Your answer
Last Name *
Your answer
Email *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Country *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Hebrew Name
Your answer
Name as it appears on Passport *
Your answer
Gender *
Home Phone
Your answer
Cell Phone *
Your answer
Father's Name *
Your answer
Father's Address *
Your answer
Father's City *
Your answer
Father's State *
Your answer
Father's Zip *
Your answer
Father's Phone *
Your answer
Father's Email *
Your answer
Father's Occupation *
Your answer
Mother's Name *
Your answer
Mother's Address
(If different from above, otherwise you may leave blank)
Your answer
Mother's City
Your answer
Mother's State
Your answer
Mother's ZIP
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Mother's Phone *
Your answer
Mother's Email *
Your answer
Mother's Occupation *
Your answer
Were either you or at least one of your parent's born in Israel? *
If you are an Israeli citizen, what is your current status regarding military service? *
Israel Emergency Contact *
Your answer
Home Town Emergency Contact : *
Your answer
Please provide names and ages of siblings, as well as where they currently attend school and what Israel programs they have attended *
Your answer
Family's religious affiliation
Your current religious affiliation
Name of synagogue
Your answer
Current or most recent school *
Your answer
Years of Jewish day school
Your answer
High school(s) attended (include name and years) *
Your answer
Middle school(s) attended *
Your answer
Other Jewish education (ex. Hebrew school) *
Your answer
High school GPA
American student only
Your answer
SAT Verbal score
Your answer
SAT Math Score
Your answer
English speaking proficiency *
No english proficiency
Very proficient
English reading/writing proficiency *
No english proficiency
Very proficient
Hebrew speaking proficiency *
No hebrew proficiency
Very proficient
Hebrew reading/writing proficiency *
No hebrew proficiency
Very proficient
Extracurricular activities
Your answer
Leadership positions (include years held)
Your answer
Prizes/awards
Your answer
Work experience (include dates)
Your answer
What do you plan to do the year following participation on The Golden Leaves Institute?
Your answer
Which universities are you considering after Golden Leaves Institute?
Your answer
Past trips to Israel
Your answer
How did you hear about The Golden Leaves Institute? *
Your answer
Please let us know who recommended us to you
Your answer
What other programs for your year are you considering?
Your answer
Please provide 3 references, including at least 1 Rabbi/youth advisor and 1 teacher/Israel advisor *
Please describe your relationship to each reference
Your answer
I would like to be considered for the following financial aid options
Need-based grant will require submission of financial data
Height *
Your answer
Weight *
Your answer
Have you or any members of your immediate family ever suffered from: asthma,allergies, digestive tract disorders, blood disorders, cancer, heart condition,epilepsy, or other notable illness? *
If yes, please describe
Your answer
Have you ever undergone surgery or had a prolonged illness? *
If yes, please describe
Your answer
Have you or any members of your immediate family ever suffered from a mental illness, emotional disturbance, depression, autism spectrum disorders, anxiety or eating disorders? *
If yes, please describe
Your answer
Do you take any prescribed medications? *
If yes, please describe
Your answer
Have you been ever been diagnosed with a learning disability? *
If yes, please describe
Your answer
Do you take medication for a learning disability? *
If yes, please describe
Your answer
---Essay
Please answer ONE of the following two questions.
1) What do you hope to achieve during your year in Golden Leaves?
Your answer
2) Describe a personal experience that shaped who you are today
Your answer
Anything else you want to tell us about yourself
Your answer
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