2014 Havurah Camper Application

2014 CAMPER APPLICATION

Required of all 1st-time Havurah participants
Summer Leadership Program for Teens from the Russian-Speaking Jewish Community
How did you hear about Havurah?
- Name of Young Judaea Camp
- From whom did you learn about the program?
- Number of teens applying
- Basic Camper Information
  
  Please complete fully for prospective Havurah camper
- Name
  
  First NameLast Name
- Gender
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- E-mail
- Home Phone
  
  Area CodePhone Number
- Cell Phone
  
  Area CodePhone Number
- Date of Birth
  
  MonthDayYear
- Current Grade
  as of 2013-2014 school year
- School Name
- Camper's Place of Birth
- City
- State/Province
- Country
- Date of Immigration to USA/Canada/Israel (if applicable)
  
  MonthDayYear
- Does Teen #1 attend religious Jewish day school?
- Has Teen #1 attended a Jewish sleep away summer camp(s) for 19+ consecutive days?
- Please provide the name(s) of other camps
- Indicate the number of previous summers teen has attended other Jewish summer camp(s)
- Basic Camper Information
  
  Please complete fully for prospective Havurah camper
- Name
  
  First NameLast Name
- Gender
- Home Address (only need to complete if different from address above)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- E-mail
- Home Phone
  
  Area CodePhone Number
- Cell Phone
  
  Area CodePhone Number
- Date of Birth
  
  MonthDayYear
- Current Grade
  as of 2013-2014 school year
- School Name
- Camper's Place of Birth
- City
- State/Province
- Country
- Date of Immigration to USA/Canada/Israel (if applicable)
  
  MonthDayYear
- Does Teen #2 attend religious Jewish day school?
- Has Teen #2 attended a Jewish sleep away summer camp(s) for 19+ consecutive days?
- Please provide the name(s) of other camps
- Indicate the number of previous summers teen has attended other Jewish summer camp(s)
- Basic Camper Information
  
  Please complete fully for prospective Havurah camper
- Name
  
  First NameLast Name
- Gender
- Home Address (only need to complete if different from address above)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- E-mail
- Home Phone
  
  Area CodePhone Number
- Cell Phone
  
  Area CodePhone Number
- Date of Birth
  
  MonthDayYear
- Current Grade
  as of 2013-2014 school year
- School Name
- Camper's Place of Birth
- City
- State/Province
- Country
- Date of Immigration to USA/Canada/Israel (if applicable)
  
  MonthDayYear
- Does Teen #3 attend religious Jewish day school?
- Has Teen #3 attended a Jewish sleep away summer camp(s) for 19+ consecutive days?
- Please provide the name(s) of other camps
- Indicate the number of previous summers teen has attended other Jewish summer camp(s)
- Parent/Guardian 1
  
  Primary contact
- Parent/Guardian Name
  
  First NameLast Name
- Home Address (ONLY if different from camper's)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- E-mail
- Home Phone
  
  Area CodePhone Number
- Cell Phone
  
  Area CodePhone Number
- Work Phone
  
  Area CodePhone Number
- Parent/Guardian 1 Place of Birth
  
  Please indicate the birth country, city and state (if applicable) of Parent/Guardian #1 below.
- City
- State/Province
- Country
- Date of Immigration to USA/Canada/Israel (if applicable)
  
  MonthDayYear
- Parent/Guardian 2
  
  Secondary contact
- Parent/Guardian Name
  
  First NameLast Name
- Home Address (if different from camper's)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- E-mail
- Home Phone
  
  Area CodePhone Number
- Cell Phone
  
  Area CodePhone Number
- Work Phone
  
  Area CodePhone Number
- Parent/Guardian 2 Place of Birth
  
  Please indicate the birth country, city and state (if applicable) of Parent/Guardian #2 below.
- City
- State/Province
- Country
- Date of Immigration to USA/Canada/Israel (if applicable)
  
  MonthDayYear
- Family Jewish Community Involvement
  
  This information is necessary to confirm scholarship eligibility
- Does family belong to a synagogue?
- Does family belong to a Jewish Community Center?
- How many of the camper's parents/guardians are Jewish?
- Personal Response
  
  To be completed by each prospective Havurah camper
- In one to two paragraphs, please explain why it is important to you to participate in a Jewish summer program.
- TEEN #2: In one to two paragraphs, please explain why it is important to you to participate in a Jewish summer program.
- TEEN #3: In one to two paragraphs, please explain why it is important to you to participate in a Jewish summer program.
- CAPTCHA
- Should be Empty:

2014 CAMPER APPLICATION

Basic Camper Information

Basic Camper Information

Basic Camper Information

Parent/Guardian 1

Parent/Guardian 2

Family Jewish Community Involvement

Personal Response