goMEOR - Apply : Maimonides Program

* First Name:

* Last Name:

* Gender:

Female

Male

* Date of Birth:

(mm-dd-yyyy)

* Email address:

* Mobile Phone:

* What University are you currently attending?

* Name of Maimonides campus you wish to attend:

* Semester for which applying:

Permanent Contact Information:

* Residence of:

* Street:

Unit #:

* City:

* State:

* Zip Code:

* Country:

Home Phone:

Family Background:

Mother's First Name:

Father's First Name:

Mother's Last Name:

Father's Last Name:

Mother's Occupation:

Father's Occupation:

Mother's Phone (in case of emergency):

Father's Phone (in case of emergency):

* What religion were you born into?

* Into what religion was your biological mother born?

* Into what religion was your biological father born?

* Into what religion were your maternal grandparents born?

* Into what religion were your paternal grandparents born?

* Given your family's religious history, with which religion do you associate yourself?

* Please provide details of any conversions below. If not applicable, please type "none."

Please list the names and ages of your siblings:

Do you have any special health needs?

Yes

Explain:

Are you currently taking any medication?

Yes

Explain:

* Who referred you to this program?

General Education History:

High School	Location	Dates	Degree or Certificate Awarded

College or University	Location	Dates	Degree or Certificate Awarded

Jewish Education History:

* What is the highest level of Jewish education with which you've been involved?

What post-high school Jewish programs have you attended? (list the programs, comma-separated. If none, type in “none”):

Did you go to a Jewish High School? If so, which one?

If you attended afternoon Hebrew School, how many years did you attend?

What was the Jewish affiliation of your Hebrew School?

If you attended Jewish Day School, till what grade did you attend?

What was the Jewish affiliation of your day school?

How would you describe your current Jewish affiliation?

How would you describe your Hebrew speaking skills?

How would you describe your Hebrew reading skills?

Please describe any leadership/professional positions you’ve held in Jewish organizations.

What Jewish schools (if any) did you attend?

School	Location	Dates Attended	Degree or Certificate Awarded

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.

* What extracurricular activities, hobbies and organizations are you involved in? Please describe your participation in them.

My top four life priorities are:
* 1.
* 2.
* 3.
* 4.

* 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.

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