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?

Teen #1
Basic Camper Information

Please complete fully for prospective Havurah camper
Name *

First Name Last Name
Gender *

Male Female
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Date of Birth *

Month Day Year
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)

Month Day Year
Does Teen #1 attend religious Jewish day school?

Yes No
Has Teen #1 attended a Jewish sleep away summer camp(s) for 19+ consecutive days?

Yes No

Other Camp Info
Please provide the name(s) of other camps
Indicate the number of previous summers teen has attended other Jewish summer camp(s)

Other Camp Info - Teen #2
Has Teen #2 attended a Jewish sleep away summer camp(s) for 19+ consecutive days?

Yes No
Please provide the name(s) of other camps
Indicate the number of previous summers teen has attended other Jewish summer camp(s)

Teen #3
Basic Camper Information

Please complete fully for prospective Havurah camper
Name *

First Name Last Name
Gender *

Male Female
Home Address (only need to complete if different from address above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Date of Birth *

Month Day Year
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)

Month Day Year
Does Teen #3 attend religious Jewish day school?

Yes No
Has Teen #3 attended a Jewish sleep away summer camp(s) for 19+ consecutive days?

Yes No

Other Camp Info - Teen #3
Please provide the name(s) of other camps
Indicate the number of previous summers teen has attended other Jewish summer camp(s)

PART II: FAMILY INFORMATION
Parent/Guardian 1

Primary contact
Parent/Guardian Name *

First Name Last Name
Home Address (ONLY if different from camper's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone 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)

Month Day Year
Parent/Guardian 2

Secondary contact
Parent/Guardian Name *

First Name Last Name
Home Address (if different from camper's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone 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)

Month Day Year
Family Jewish Community Involvement

This information is necessary to confirm scholarship eligibility
Does family belong to a synagogue? *

Yes No
Does family belong to a Jewish Community Center? *

Yes No
How many of the camper's parents/guardians are Jewish? *

0 1 2

PART III: CAMPER ESSAY
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