Student Information Form

First Name  Last Name
Preferred Email Address
Phone Number  Dorm
Graduating Year
Home Address  
City  State  Zip
Are you Eligible for Birthright Israel?  (You must be between 18-26, Jewish, and never been to Israel on a peer tour.)  

Are you interested in receiving more information about Chabad's Kosher Dinner plan?
 

Please use the space below to tell us about what you are looking for in Jewish Life during your college years.

At Chabad, we stay in touch with the parents of our students, giving them an opportunity to provide care packages during finals and high holidays. Please take a moment to supply us with your parents' contact information.

Father's Information
First Name  Last Name
Preferred Email Address
Phone Number  
Check if the address is the same as yours. Otherwise,
Home Address  
City  State  Zip

Mother's Information
First Name  Last Name
Preferred Email Address
Phone Number  
Check if the address is the same as yours. Otherwise,
Home Address  
City  State  Zip

Comments

Please type "yes" in the box below to confirm your submission