Poland Trip Application
Thank you for your interest in the Poland Trip. Help us get you started on your application by providing some basic information below. All Poland participants are obligated to make a financial commitment toward their trip. We will be in touch with you regarding your obligation.
If you would like someone to contact you by phone, please be sure to submit your phone number as well.
Program and Preferred Dates
Programs *
General Information
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Email Address *
Your answer
Mobile Phone *
Your answer
Passport No:
Your answer
Passport Exp. Date
MM
/
DD
/
YYYY
Full Name on Passport
Your answer
Gender *
Family Background
Father's First Name
Your answer
Father's Last Name
Your answer
Mother's First Name
Your answer
Mother's Last Name
Your answer
Is Your Father Jewish? *
Is Your Mother Jewish? *
Given Your Family History, With Which Religion Do You Associate Yourself With? *
Your answer
General Education History
University or College
Your answer
What degree are you pursuing
What year did you begin school?
Your answer
If you are not in school, how would you describe your current vocation?
Your answer
In what extracurricular activities etc. are you involved? Please describe in what way you participate.
Your answer
Special Requirements
Do you currently have, or did you in the past have any special health needs about which we should be aware? *
If so, please elaborate:
Your answer
Do you have any special dietary requirements? *
If so, please elaborate:
Your answer
Are you currently taking any medication?
If so, please elaborate:
Your answer
Have you ever been hospitalized
Is so, please elaborate:
Your answer
Personal Statement
How did you hear about the program? *
Your answer
Please state your reasons for wanting to attend the Poland trip: *
Your answer
An interview is required for all qualified applicants.

Also, by submitting this application you are certifying that everything you have filled out is true to the best of your knowledge. Full and honest reporting is essential for effective review by the application review board and misrepresentations could result in the applicant being responsible for the value of his or her scholarship awarded on the basis of false information.

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