* First Name:
* Last Name:
* Gender:
* Date of Birth:
(mm-dd-yyyy)
* What University are
you currently attending?
* Name of Maimonides
campus you wish to attend:
------------------------
American University
Binghamton University
Boston University
Brandeis University
Brown University
Cornell University
Drexel University
Emory University
Georgetown University
George Washington University
Harvard University
Massachusetts Institute of Technology
New York University
Northwestern University
Rutgers University
Stanford University
Temple University
Tufts University
University of California at Berkeley
University of Georgetown
University of Maryland
University of Pennsylvania
Yale University - The Vaad
* Semester for which applying:
------------------------
Summer 10
Fall 10
Spring 11
Your Address at
School:
Street:
Unit #:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S. Georgia and S. Sandwich Islands
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and The Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Soviet Union
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
US Minor Outlying Islands
US Virgin Islands
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Home Phone:
* Mobile Phone:
School Phone:
* Email address:
Family Background:
* What religion were you born into?
* Into what religion was your biological mother born?
None
Judaism
Christianity
Buddhism
Muslim
None
Other
* Into what religion was your biological father born?
None
Judaism
Christianity
Buddhism
Muslim
None
Other
* Into what religion were your maternal grandparents born?
None
Judaism
Christianity
Buddhism
Muslim
None
Other
* Into what religion were your paternal grandparents born?
None
Judaism
Christianity
Buddhism
Muslim
None
Other
* Given your family's religious history, with which religion do you associate yourself with today?
Please provide details, including details of any conversions.
Please list the names and ages of your siblings:
Do you have any special health needs?
Explain:
Are you currently taking any medication?
Explain:
* Who referred you to this program?
General Education History:
Jewish Education History:
* What is the highest level of Jewish education with which you've been involved?
------------------------
Virtually None
Hebrew School/Sunday School (pre age-13)
Hebrew School/Sunday School (post age-13)
Jewish Elementary School
Jewish High School
Post High School Jewish Education
If you attended afternoon Hebrew School, how many years did you attend?
What was the Jewish affiliation of your Hebrew School?
Reform
Conservative
Orthodox
Reconstruction
Unaffiliated
Other
------------------------
If you attended Jewish Day School, till what grade did you attend?
------------------------
Kindergarten
Elementary School
Middle School
High School
What was the Jewish affiliation of your day school?
------------------------
Reform
Conservative
Orthodox
Reconstruction
Unaffiliated
Other
How would you describe your current Jewish affiliation?
------------------------
Conservative
Orthodox
Other
Reconstructionist
Reform
Unaffiliated
How would you describe your Hebrew speaking skills?
------------------------
Not at all
Minimal
Average
Very well
How would you describe your Hebrew reading skills?
------------------------
Not at all
Minimal
Average
Very well
Please describe any leadership/professional positions you’ve held in Jewish organizations.
What Jewish schools (if any) did you attend?
What other types of Jewish experiences have you had? (Bar/Bat Mitzvah, Youth Group, Fraternity/Sorority, etc.)
If involved, please list your Greek Life association.
* In two paragraphs,
please explain what you hope to gain from the Maimonides Leaders Fellowship
program.
All personal information will be held in
strict confidence.
I affirm that all the information provided in this application is
true, and understand the Maimonides Leaders Fellowship guidelines enumerated
below:
1) I understand that in order to receive the full fellowship I
will need to attend all the program components including weekday seminars,
weekend events, and graduation. I also understand that failure to attend the
above-stated events will result in a prorated deduction from program stipend.
2) I will comply with all basic standards of program conduct in a
manner befitting a Maimonides Fellow. MLF reserves the right to ask any fellow
to discontinue participation for any reason it sees fit. In such event the
student will not receive any Fellowship funds.
3) A personal interview may be required before final admission.