Application for JAM AIPAC Trip

 Contact Information

 First Name
 Last Name
 Which trip are you applying for?
 Date of Birth

 Home Address


 Cell Phone

 E-Mail Address

 Family Information

 Father’s Name
 Mother’s Name
 What is your father's occupation?
 What is your mother's occupation?
 Parent’s Phone Number
 Where was your father born?
 Where was your mother born?

 Parent’s Marital Status

 Is your Mother born Jewish?

 Is your Father born Jewish?

 List the names, ages of your siblings





 Educational Information

 Current year in school
 Which high school did you attend?
 Have you participated in an Aipac national conference in Washington, D.C. in the past?
 List the extracurricular activities you have been involved in including high schol, sports, music, art, clubs etc..
 Please list your past jobs (entries in chronological order, beginning with the most recent.)




Miscellaneous Information

 Do you have any “formal’” Jewish Education?  If so, please list the Jewish schools you attended together with the dates.

 Have you ever sought psychological counseling?
How did you hear about this trip, or who referred you?
 Are you or have you been, a member of a Jewish organization?  If so, which one.

 Describe your Jewish observance:


 Are you taking any type of medication?

 Do you have any special medical need?

 Do you know people coming on this trip or any of our other trips?  If so, who?




List any areas in your life that you demonstrated activism or passion on behalf of the State of Israel.

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