Gap Year – Machon Chana Application Hub

I. Personal Background

Program Applying for(Required)

Arrival Date(Required)

When would you like to begin your studies? (could be approximate date)

Title

Name(Required)

First Last

Hebrew Name(Required)

Please enter “no” if you don’t have

Current Mailing Address(Required)

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

Mobile Phone(Required)

Email(Required)

Country of Citizenship(Required)

Social Security/ Passport Number(Required)

Age(Required)

Date of Birth(Required)

Place of Birth(Required)

City

State / Province

Country

Permanent Address(Required)

Same as my Current Mailing Address

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

Is there anyone else living at this address?(Required)

Person(s) living with you

Name

Relation to you

Occupation(Required)

Studying

Studying and working

Working

Other

Employer Name(Required)

First Last

Employer Phone Number(Required)

Father/ Legal Guardian Name(Required)

First Last

His Hebrew Name(Required)

Please enter “no” if he doesn’t have

Father's Address

Same as my Current Mailing Address

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

Please enter the address if different than yours

His Phone Number(Required)

His Email(Required)

Mother/ Legal Guardian Name(Required)

First Last

Her Hebrew Name(Required)

Please enter “no” if she doesn’t have

Mother's Address

Same as my Current Mailing Address

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

Please enter the address if different than yours

Her Phone Number(Required)

Her Email(Required)

Was your mother born Jewish?(Required)

Please upload your mother's or your conversion papers(Required)

Max. file size: 128 MB.

Please upload your recent picture(Required)

Max. file size: 128 MB.

References

Please submit two references, including a rabbi or rebbetzin and, preferably, a Jewish community/ campus leader or someone who knows you well. Please list the people who will be submitting references on your behalf and DETAILED letters of recommendation written on the business or personal letterhead of the person submitting the letter.

Rabbi/Rebbetzin who referred you(Required)

Name

Phone Number

Email

Address(Required)

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

Synagogue or temple your family is part of(Required)

Name

Phone Number

Email

Address(Required)

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

High School Information(Required)

Name of the School

Grade Completed

Phone Number

Email

Please prepare 3 references from your school

Upload School Reference #1(Required)

Max. file size: 128 MB.

Upload School Reference #2(Required)

Max. file size: 128 MB.

Upload School Reference #3(Required)

Max. file size: 128 MB.

Application Objective

Why do you want to learn at Machon Chana, and what are your goals for attending the school?(Required)

How or from whom did you hear about the Chabad Gap Year program?(Required)

II. Education, Jobs, and Activities

Jewish Education(Required)

Name of Institution

Address

Program attended (e.g. day school, Talmud Torah, Yeshiva)

Affiliation (e.g. Reform)

Length of Time attended

Please list the last three schools attended, beginning with the most recent or current institution

Secular Education(Required)

Name of Institution (e.g. university, vocational school)

Address

Major, Field of Study, Curriculum

Status (e.g. B.A., Master's, current student)

Date Completed

Please list the last three colleges and post-secondary schools attended, beginning with the most recent or current program of study

Jobs(Required)

Company Name

City, State, Country

Job Title or Position Held

Date Job Started

Date Job Ended

Please list the last three jobs or positions held beginning with most recent or current job

Activities: Organizations and Groups(Required)

Name of Organization or Group

City, State, Country

Job Title or Position AND Brief Description of Activities

Date Active from

Date Active to

Please list the last three organizations or groups with which you have been involved, listing the most recent first

Please describe any additional areas of special interest, ability, knowledge, skill, and any other hobbies or pursuits(Required)

IV. Medical Form

All information will remain strictly confidential and will only be used by medical providers in case of medical necessity while the student is in school. Students with pre-existing health conditions must have medical insurance/coverage or proof of ability to pay for any necessary medical treatment and medication. If there is a medical condition that affects one’s attendance of classes, she will need to return home to care for her health. By signing this form you agree to pay for any costs associated with health care that may not be covered by your insurance should the staff determine you are in need of such.

Name of Student(Required)

Date of Birth(Required)

In case of emergency contact:(Required)

Name

Relation to you

Emergency Contact Address(Required)

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

Emergency Contact Phone Number(Required)

1. Do you have any special dietary requirements?(Required)

Please provide details

2. Do you now or have you ever suffered from an eating disorder?(Required)

Please provide details

3. Have you ever received psychological counseling?(Required)

Please provide details

4. Do you suffer from any mental or emotional illnesses?(Required)

Please provide details

5. Do you suffer from any allergies?(Required)

Please provide details

Please indicate allergies to medications as well

6. Do you suffer from asthma, eczema or hives?(Required)

Please provide details

7. Do you suffer from any of the following?(Required)

Tuberculosis

Epilepsy

Heart diseases

Respiratory illnesses

Diabetes

Digestive tract diseases (such as chronic constipation or diarrhea)

Any other significant illness

None

Please provide details

8. Did you have any hospitalizations and surgeries in the past?(Required)

Please provide details

Month/Year

Length of Hospitalization

Diagnosis

9. Do you have any physical limitations?(Required)

Please provide details

10. Do you take any medication(s)?(Required)

Please list name of medication(s) and reason for use

11. Are you allergic to any medication(s)?(Required)

Please provide details

Is it there any other information regarding your health which you feel we should know about?

I have read the above and affirm that all information contained on this application is true and accurate to the best of my knowledge. Falsifying or purposefully leaving out any information on this medical form is cause for immediate expulsion from the school and dorm, as well as cancellation of the student visa in case of foreign students. If there is medical information that a prospective student deems extremely confidential and does not wish to write on this for it must be discussed orally with Mrs Labkowski.

Applicant's or Parent/Legal Guardian's Signature

Applicant's or Parent/Legal Guarsian's Name(Required)

Please type in your full name

Date(Required)

V. Payment Information

Thanks to an anonymous sponsor, a select group of students are eligible to participate in this program for free (all you pay for is your air fare). We will notify you if you are approved.

Machon Chana Application Hub

Gap Year Application

I. Personal Background

References

Application Objective

II. Education, Jobs, and Activities

III. Jewish Affiliation, Background, and Knowledge

Level of knowledge

Foreign Students

IV. Medical Form

V. Payment Information