Application for the Akiva Israel and Poland Trip

Your Info

Input name exactly as it appears on your passport

First Name*

Middle Name

Last Name*

Gender*

Male
Female

Date of Birth*

Trip Info

Akiva Israel Trip Dates

Aug 15 - 31, 2016
Jan 3 - 15, 2017
May 14 - 29, 2017

Price Options

Akiva Group Flight - $3,500
Flight not included - $1,800

Country of Citizenship*

Full Name as you would like it to appear on a name tag:

How did you hear about Akiva?*

Referring individual or organization:*

Highest Jewish Education

Yeshiva/Seminary Information

Year Finished Yeshiva/Seminary:*

Please Specify Yeshiva/Seminary:*

Highest Secular Education:

College Information

Year of Graduation:*

University / College:*

Please Specify University:

Major:

Please Specify Graduation Status:

Employment Information

(Mandatory if graduated)

Current Employer:*

Job Title:*

Check if unemployed / in school

Unemployed

Your Contact Information

Your Current Address:*

Street Address City State / Province / Region ZIP / Postal Code Country

Cell Phone:*

A phone number we can reach you personally on

Home Phone:*

This can be your parents home number

Your Email:*

Enter Email Confirm Email

Permanent / Parent's Address

Where do you call home?*

Living Situation:*

Check if same as address above

Same Address

Permanent Residence Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Background

Mother's First Name:*

Mother's Last Name:*

Mother's Occupation:*

Father's First Name:*

Father's Last Name:*

Father's Occupation:*

Was your birth father born Jewish?*

Yes
No

Was your birth mother born Jewish?*

Yes
No

Were all your grandparents born Jewish?*

Yes
No

Please summarize fathers conversion history if any:

Please summarize mothers conversion history if any:

Please summarize grandparents Jewish history:

Parents Marital Status:*

Parents Jewish Affiliation:*

Please specify Parents Jewish affiliation:*

Educational History

What extracurricular activities, hobbies and organizations are you involved in?*

What Jewish Education have you had?*

How would you describe your Jewish education?*

How are your Hebrew skills?*

Do you hold any leadership/professional positions in Jewish organizations?*

Yes
No

Position:*

Shidduch Profile

Your Marital Status:*

Do you have any children?*

Yes
No

Hashkafa:*

Torah Observant Since:*

Ethnic Background*

Ashkenaz
Sephardic

For me, living in Israel:*

Location where I grew up:*

My Primary Personality Trait:*

My Secondary Personality Trait:*

Personal:

Height:

Do you smoke?*

Yes
No

Do you plan on covering your hair?*

Yes
No

Do you plan on only wearing skirts?*

Yes
No

I keep kosher:

My top 4 life priorities are:

1*

2*

3*

4*

Character 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

Please add at least 3 References

Reference - Name

First Last

Relationship to Reference:

Phone:

Best time to call them:

Special Requirements

Do you have any accessibility requirements or physical limitations or restrictions?*

Yes
No

Please elaborate:*

Do you have any special dietary requirements?*

Yes
No

Please elaborate:*

Are you currently receiving medical treatment or psychological counseling?*

Yes
No

Please elaborate:*

Are you currently taking any medication?*

Yes
No

Please list your medications:*

Click on the plus button on the right to add a line

Have you ever been hospitalized?*

Yes
No

Please explain:*

Upload a Photo of Yourself:

Drop files here or

Your Sweatshirt Size:*

Please note: Israeli sizes run smaller than U.S. sizes. You may want to select 1 size larger.

Would you like to be contacted about ordering an Israeli phone, sim card or mifi device for the trip? (highly recommended)*

Someone from the phone company will contact you about ordering the best device to fit your needs. All orders will be waiting for you when you arrive in Israel.

Yes
No

Passport Number:

Passport Expiration Date:

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Your Info

Trip Info

School Information

Employment Information

Your Contact Information

Permanent / Parent's Address

Family Background

Educational History

My top 4 life priorities are:

Character References

Special Requirements

Survey

Your Info

Trip Info

Your Contact Information

Your Info

Trip Info

Yeshiva/Seminary Information

College Information

Employment Information

Your Contact Information

Permanent / Parent's Address

Family Background

Educational History

Shidduch Profile

Personal:

My top 4 life priorities are:

Character References

Please add at least 3 References

Special Requirements