General Information
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First Name:
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Last Name:
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Date of Birth:
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Country of birth:
Passport Country and Number:
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Gender:
Please Select
Male
Female
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How did you hear about the program?
Please Select
Aish.com website
Aish Hatorah branch
Email
Friend/Relative
Flyer
Newspaper article or Ad
Past participant
Websearch
Other
Employment Information
Current Employer:
Job Title:
Your Immediate Family and Contact Information
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Address:
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City:
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State/Province:
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Zip:
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Country:
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Phone Number:
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Phone Number Cell:
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Phone Number Work:
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E-Mail:
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Your Marital Status:
Please Select
Single
Married
Separated
Divorced
Widowed
Name:
Email:
Cell:
Year Married:
Spouse's religious observance:
:
Was your husband born Jewish:
Please Select
Yes
No
Please summarize conversion history if any:
Husband's Employer:
Husband's Job Title:
Number of Children:
Children's name and ages:
Number of children in College:
Number of children growing in Torah Observance(Baalei Teshuva):
Parents' Contact Information If Applicable
Residence of?
Please Select
Parents
Mother
Father
Address:
City:
State/Province:
Zip:
Country:
Phone/Cell:
E-Mail:
FAMILY BACKGROUND
Mother's First Name:
Mother's Last Name:
Mother's Occupation:
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Father's First Name:
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Father's Last Name:
Father's Occupation:
Parents' Marital Status when living:
Please Select
Married
Separated/Divorced
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Was your father born Jewish?
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Was your mother born Jewish?
Parents' Jewish affiliation
Please Select
Reform
Conservative
Orthodox
Unaffiliated
Recently becoming observant
Other systems explored or observing
Were all your grandparents born Jewish?
Please Select
Yes
No
If no, please explain
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Are you adopted?
Please Select Yes
No
Was your birth mother born Jewish?
Please Select
Yes
No
Don't Know
Was your birth father born Jewish?
Please Select
Yes
No
Don't Know
EDUCATIONAL HISTORY
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How many years of education (starting with first grade) completed?
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What extracurricular activities, hobbies and organizations are you involved in? Please describe your participation in them:
JEWISH BACKGROUND
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What Jewish education have you had?
Please Select
Virtually None
Hebrew School/Sunday School (pre age-13)
Hebrew School/Sunday School (post age-13)
Jewish Day School
Yeshiva High School
If attended Hebrew School, what was its Jewish Affiliation?
Please Select
Reform
Conservative
Orthodox
Unaffiliated
If you attended Day School, how many years did you attend?
If attended Day School, what was its Jewish Affiliation?
Please Select
Reform
Conservative
Orthodox
Unaffiliated
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Your current Jewish Affiliation:
Please Select
Reform
Conservative
Orthodox
Unaffiliated
Recently becoming observant
Other systems explored or observing
Convert to Judaism, Orthodox
Convert to Judaism, Other
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How would you describe your Jewish education?
Please Select
Insufficient
Complete
Other
If you specified "other", please explain:
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How well can you speak Hebrew?
Please Select
Introductory
Intermediate
Fluent
Other
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How would you describe your Hebrew reading skills?
Please Select
Introductory
Intermediate
Advanced
Do you hold any leadership/professional positions in Jewish organizations?
Please Select Yes
No
If Yes, What Position and Organization?
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Have you been to Israel before?
Please Select
Yes
No
If yes, how many times and when was your last visit?
If yes, in what context? (touring, living, visiting family or friends, learning, on a program, with family, etc)
What types of Jewish experiences have you had? (Bat Mitzvah, youth group, fraternity/sorority, etc.)
Current Congregation Name and City:
Rabbi of Congregation:
Rabbi's Phone:
Jewish Organizations you are a member of/ Details:
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
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Name:
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Relationship:
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Address:
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Phone Number:
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Best time to reach him/her
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E-Mail:
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Name:
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Relationship
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Address:
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Phone Number:
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Best time to reach him/her
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E-Mail:
SPECIAL REQUIREMENTS
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Do you have any accessibility requirements or physical limitations or restrictions?
Please Select
Yes
No
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Do you have any special dietary requirements?
Please Select
Yes
No
If so, please elaborate.
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Are you currently taking any medication?
Please Select
Yes
No
If so, please elaborate.
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Are you currently receiving medical treatment?
Please Select
Yes
No
If so, please elaborate.
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Treatment for Psych disorder:
If so, please elaborate.
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Have you ever been hospitalized?
Please Select
Yes
No
If so, please elaborate.
List any allergies:
Are you active in sports, if so, which?
Language Skills:
EMERGENCY CONTACT INFORMATION
Name of Emergency Contact:
Phone for Emergency Contact:
Emergency Contact Email:
SURVEY
Are you a practicing Jew?
Please Select 1- Not regularly
2- Quarterly
3- Monthly
4- Weekly
5- Major Holidays
6- Shabbat & Kosher
7- Fully Observant
Comp to others, Jewish causes are:
Please Select 1- Less important
2- Equally important
3- More important
4- A priority & obligation
Desire to be close to Jewish people:
Please Select 1- Prefer not to associate with Jewish people
2- Indifferent
3- Nice but not necessary
4- It's a strong preference
Has Aish attributed to your growth?
Please Select 1- Not at all
2- Somewhat
3- Significantly
4- Entirely
How do you identify yourself?
Please Select
1- Primarily American (or other nationality)
2- More American (or other) than Jewish
3- Equally American (or other) & Jewish
4- More Jewish than American (or other)
How is Torah relevant to you?
Please Select 1- Not relevant
2- Only Culturally
3- Nice practical ideas & ideals
4- A serious source of wisdom
How often do you help fellow Jews?
Please Select 1- Not regularly
2- Monthly
3- Twamo (2 times a month)
4- A few times a week
How often do you learn torah?
Please Select 1- Not regularly
2- Monthly
3- two times a month
4- Few times a wk
What is your attitude to marriage?
Please Select 1- Religion is not a criteria
2- Nice, but not a criteria
3- Prefer a Jew but will date non-Jews
4- Will only date and marry Jews
Will (or does) your children's education have:
Please Select 1- No extra Jewish emphasis
2- Extra curricular Jewish schooling
3- Any Jewish day school
4- Religious Jewish day school
