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Yeshivacation Application

I. Personal Information

Name(Required)

First Last

Hebrew Name

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone where you can be reached(Required)

Email(Required)

Date of Birth(Required)

Month

Day

Year

Hebrew Date of Birth

Month

Day

Year

Date of arrival(Required)

Month

Day

Year

Do you have any special dietary requirements, allergies?(Required)

If yes, Please provide details

Do you take any medication(s) or allergic to any medication?(Required)

If yes, Please provide details

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relation

Relationship of Emergency Contact to you

Highest Grade Completed

Some High School

High School

Some College

College

Certificate

BA, BS

MA, MS

PhD

Professional Training

Current Occupation

What is your primary language?

What other languages do you speak?

Please add a picture(Required)

Max. file size: 128 MB.

II. General Information

Why are you interested in learning at Yeshivacation?

What are you hoping to gain from this program?(Required)

Please tell us any additional information you feel we should we know:

III. Jewish Background

Describe your level of observance and for how long:(Required)

Are you a convert to Judaism?

If yes, who was the converting Beth Din?

Please upload your conversion papers(Required)

Drop files here or

Max. file size: 128 MB.

What is your most positive and negative Jewish experience?

What is your general view of the Lubavitch movement?

Jewish Contact/Referral #1 Name(Required)

Rabbi, Shliach, or a head of a Jewish organization that knows you well

Jewish Contact/Referral #1 Phone(Required)

Jewish Contact Referral #1 Relation

What is your contact’s relationship to you?

Jewish Contact/Referral #2 Name

Rabbi, Shliach, or a head of a Jewish organization that knows you well

Jewish Contact/Referral #2 Phone

Jewish Contact Referral #2 Relation

What is your contact’s relationship to you?

Join our Email List/Newsletter

Email List

Newsletter

Permission to be included in pictures and videos for promotional purposes.(Required)

I agree

I don’t agree

What program are you registering for?(Required)

Winter

Summer

Winter Yeshivacation

Early Bird (Until Dec 1st) – $1,550

Full price – $1,650

Application Fee – $50

Application fee is included in the price and is not refundable.

Summer Yeshivacation (Price: $1,600)

Early Bird (Until June 2025)

Full program (4 weeks)

Pay Later (Application Fee Applies)

Refunds will involve a cost to the applicant (Up to 6%)(Required)

I understand and accept

Payment Method

Feed Required: To use the PayPal Checkout field, please create a PayPal Checkout feed for this form.

Coupon Code

Total

Credit Card

Δ

Yeshivacation Application

I. Personal Information

Name(Required)

First Last

Hebrew Name

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone where you can be reached(Required)

Email(Required)

Date of Birth(Required)

Month

Day

Year

Hebrew Date of Birth

Month

Day

Year

Date of arrival(Required)

Month

Day

Year

Do you have any special dietary requirements, allergies?(Required)

If yes, Please provide details

Do you take any medication(s) or allergic to any medication?(Required)

If yes, Please provide details

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relation

Relationship of Emergency Contact to you

Highest Grade Completed

Some High School

High School

Some College

College

Certificate

BA, BS

MA, MS

PhD

Professional Training

Current Occupation

What is your primary language?

What other languages do you speak?

Please add a picture(Required)

Max. file size: 128 MB.

II. General Information

Why are you interested in learning at Yeshivacation?

What are you hoping to gain from this program?(Required)

Please tell us any additional information you feel we should we know:

III. Jewish Background

Describe your level of observance and for how long:(Required)

Are you a convert to Judaism?

If yes, who was the converting Beth Din?

Please upload your conversion papers(Required)

Drop files here or

Max. file size: 128 MB.

What is your most positive and negative Jewish experience?

What is your general view of the Lubavitch movement?

Jewish Contact/Referral #1 Name(Required)

Rabbi, Shliach, or a head of a Jewish organization that knows you well

Jewish Contact/Referral #1 Phone(Required)

Jewish Contact Referral #1 Relation

What is your contact’s relationship to you?

Jewish Contact/Referral #2 Name

Rabbi, Shliach, or a head of a Jewish organization that knows you well

Jewish Contact/Referral #2 Phone

Jewish Contact Referral #2 Relation

What is your contact’s relationship to you?

Join our Email List/Newsletter

Email List

Newsletter

Permission to be included in pictures and videos for promotional purposes.(Required)

I agree

I don’t agree

What program are you registering for?(Required)

Winter

Summer

Winter Yeshivacation

Early Bird (Until Dec 1st) – $1,550

Full price – $1,650

Application Fee – $50

Application fee is included in the price and is not refundable.

Summer Yeshivacation (Price: $1,600)

Early Bird (Until June 2025)

Full program (4 weeks)

Pay Later (Application Fee Applies)

Refunds will involve a cost to the applicant (Up to 6%)(Required)

I understand and accept

Payment Method

Feed Required: To use the PayPal Checkout field, please create a PayPal Checkout feed for this form.

Coupon Code

Total

Credit Card

Δ

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