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Student Information Form

Student Information Form

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Student Information Form

First Name Last Name
Preferred Email Address
Cell Phone Number Dorm
Graduating Year Birthday
Home Address
City State Zip
Are you Eligible for Birthright Israel? (You must be between 18-26, Jewish, and not have lived in Israel since you were 12. Also, if you took a peer group trip after the age of 18, you are not eligible.)

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

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