Application For Admission

Fill out each item completely.
Upon submitting this application, a payment of $100 is required--payment details are on the next screen.
The privilege of studying at Sharei Bina is conditional on adherence to our rules and regulations. Sharei Bina reserves the right to require the withdrawal of any student for any reason it deems sufficient.
Please submit:
1. A copy of the information page of your passport
2. A letter of recommendation from a teacher or principal
3. A copy of your last report card.
All personal information will be held in strict confidence.

APPLICANT'S PERSONAL INFORMATION

Last Name: *

First Name: *

Hebrew Name: *

Date of Birth: *

Hebrew Birthday: *

Passport # and Country of Issue: *

Place of Birth: *

(City,Country)

Citizenship/s: *

Permanent Home Address: *

(Include City, State,Zip)

Home Telephone : *

Cell Phone: *

Israeli Cellphone Number: *

Email: *

Fax: *

Name & Telephone # of closest relative in Israel: *

Name & Telephone # of who to contact in case of emergency: *

FATHER'S INFORMATION

Name: *

Phone Numbers: *

Address: *

Email: *

Occupation: *

Employer:

Business Address & Phone Number:

MOTHER'S INFORMATION

Full Name at present time: *

Maiden Name: *

Phone Numbers: *

Address: *

Email: *

Occupation: *

Employer:

Business Address and Phone Number:

Were you born of a Jewish mother?: *

If you, your mother, or her mother were converted, please specify with which Rabbi, where, and when :

Please include copies of all available conversion certifications with your application.

ADDITIONAL FAMILY INFORMATION

Are your parents still married?: *

If either of your parents are remarried, please supply their spouse's names:

Please list the names of your siblings: *

Were you adopted?: *

If yes, at what age?:

FAMILY CONGREGATION

Congregation Name:

Name of your Rabbi: *

His Phone Number: *

His Email:

His Address:

REFERENCES

Please supply two references. They should be people who know you well, and at least one of them should be a teacher.

1. Name: *

Phone Numbers: *

Address:

Email: *

Relationship: *

2. Name: *

Phone Numbers: *

Address:

Email: *

Relationship: *

HEALTH QUESTIONAIRRE

It is necessary that the following questions be answered completely and honestly. Hiding any medical information is grounds for expulsion.

Please list any physical or mental condition/s you have, how it is being handled, and how it affects your life.: *

Are you presently on any medication? If yes, please list the name, dosage, and purpose of each: *

Please list other medications, and their functions, which you may bring with you to Israel, to be taken as needed: *

Were you ever hospitalized? If yes, please give (approximate) dates, reasons, how long hospitalization lasted, and any other pertinent details. Was there surgery involved?: *

Do you suffer from allergies (food, environmental, medicinal)? If yes, please describe: *

ESSAY SECTION

Please write a short autobiographical essay including family background, educational history, issues you may have been dealing with, and anything else you'd like to share.: *

Please give a general idea of your knowledge of Jewish laws and customs, and your feeling towards Judaism: *

Please list your skills, hobbies, abilities, or areas of special knowledge or interest: *

How did you hear of Sharei Bina, and why do you think it might be the right seminary for you?: *

What are your goals for this coming year, and what are you looking forward to gaining from Sharei Bina?: *

Are you in need of Financial Assistance? If yes, please explain.: