Fellowship Application

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APPLYING ON-LINE for The Hasbara Fellowships: Summer 2013

Please fill in all the required information (as denoted by *), otherwise your application will not be accepted. After submitting this application you will automatically receive a confirming email. Please notify us of any address or phone number changes at nrefael@hasbarafellowships.org or call 1-646-365-0030.

Please make sure to click the "Submit" button at the bottom of this page when you are finished filling out the form. Then, review your information on the next screen and click the "Submit" button at the bottom of that screen.
YOU MUST CLICK THE SECOND SUBMIT BUTTON IN ORDER TO APPLY.

Please use the field below to include a recent photo of yourself in gif or jpg format.
(Use the Browse button to find your picture's location on your computer. Max size is 2 MB.)

* Upload photo:

Program and Preferred Dates

Preferred Program:

General Information

*	First Name:
*	Last Name:
*	Date of Birth:	(mm/dd/yyyy)
	Passport No:
	Name as it Appears on Passport:
*	Gender:
*	How did you hear about the Program?
	Please enter the name of the referring individual or organization, if applicable:
*	Country of Birth:

School Information

*	Year of Graduation:
*	School Status:
*	University/College:
	Other University/College
*	Major
Employment Information (Mandatory if graduated)
	Current Employer:
	Job Title:

Your Contact Information

*	Address:
*	City:
*	State/Province:
*	Zip:
*	Country:
*	Phone Number:	(###-###-####)
*	Phone Number Cell/Work:	(###-###-####)
*	Personal E-mail:
*	School E-mail:
*	Your Marital Status:

Permanent/Parents' Home Address

*	Residence of:
*	Address:
*	City:
*	State/Province:
*	Zip:
*	Country:
*	Father's Emergency Phone Number:	(###-###-####) Enter "1" if N/A
*	Mother's Emergency Phone Number:	(###-###-####) Enter "1" if N/A
	Fax:	(###-###-####)
*	E-mail:

Family Background
*	Mother's First Name:
*	Mother's Last Name
	Mother's Occupation
*	Father's First Name:
*	Father's Last Name:
	Father's Occupation
*	Parents' Marital Status:

*	Was your father born Jewish? Please summarize conversion history if any
*	Was your mother born Jewish? Please summarize conversion history if any:
*	Parents Jewish affiliation
*	Were all your grandparents born Jewish? If no, please explain.

Years of Education and Activism

* How many years of education (starting with first grade) completed?

Please describe your specific role in Israel activism on campus and/or in your community:



Jewish Background
*	What Jewish Education have you had?
	If you attended afternoon Hebrew School, how many years did you attend?
	What was the Jewish Affiliation of your Hebrew School?
	If you attended Day School, how many years did you attend?
	What was the Jewish Affiliation of your Day School?
*	Your Current Jewish Affiliation:
*	How would you describe your Jewish education?
	If you specified "Other" Please expain
	How would you describe your Hebrew speaking skills?
	How would you describe your Hebrew reading skills?

*	Do you hold any leadership/professional positions in Jewish organizations?
	Position:
*	Have you been to Israel before?
	In What Context? (Bar/Bat Mitzvah, Year abroad, March of the Living, birthright israel, Yeshiva study, etc.) (Max 255 characters)
*	What types of Jewish experiences have you had? (Bar Mitzvah, youth group, fraternity/sorority, etc) (Max 255 characters)

References
	(Please include name, address, phone, relationship to you and the best time of day he or she can be reached. Please do not include family or friends
	Reference 1
	Name
	Relationship
	Address
	Phone number
	Best time to reach him/her
	Email
	Reference 2
	Name
	Relationship
	Address
	Phone Number
	Best time to reach him/her
	Email

Special Requirements
*	Do you have any accessibility requirements or physical limitations or restrictions?
	If so, please elaborate.
*	Do you have any special dietary requirements?
	If so, please elaborate.
*	Are you currently receiving medical treatment or psychological counseling?
	If so, please elaborate
*	Are you currently taking any medication?
	If so, please elaborate.
*	Have you ever been hospitalized?
	If so, please elaborate.

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Fellowship Application