Stonybrook Fellowship Application Fall 2017
First Name *
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Last Name *
Your answer
Gender *
Date of Birth *
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Address at School *
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School Phone # *
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Cell Phone # *
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Email Address *
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Permanent Address *
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How Did You Hear About The Program? *
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Is Your Mother Jewish? *
If You Answered Yes Above, Is Your Mother Jewish By Birth or Conversion? *
Is Your Father Jewish? *
If You Answered Yes Above, Is Your Father Jewish By Birth or Conversion? *
Are These Your Birth Parents? *
Do You Have Any Special Medical Needs?
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If you are taking, or have taken in the past (on a protracted basis) any medication for any aspect of your health, please indicate: *
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If Relevant, What is Your Present Occupation, Either Full Time or Part Time
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Describe Your Jewish Education Background *
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Have You Ever Been On An Organized Israel Trip or Program, Besides Birthright? If So, Please Specify What Trip. *
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Are Your Currently A Student? *
If You're Currently A Student, What Year?
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List Chronologically All The Schools You Have Attended *
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List the year of expected graduation and your intended major: *
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Clubs/Fraternities/Sororities:
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Please list any academic interests, hobbies or extracurricular activities: *
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Please explain what you hope to gain from the Maimonides Leaders Fellowship program: *
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References
First Reference Name *
Your answer
First Reference Phone Number *
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Your Relationship To First Reference *
Your answer
Second Reference Name *
Your answer
Second Reference Phone Number *
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Your Relationship To Second Reference *
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