Hillel On-Line Graduate Information Form

 
Title:  First Name*:  Last Name*:

Gender*: Male   Female     Graduation Year*:

School (Local) Address:

Line 1*:
Line 2: 
(Room #/P.O. Box (if applicable))

City*:     

State*:     Zip*:

School Phone # *:   

Cell Phone # :   

Home Address:

Line 1*:
Line 2: 
(Room #/P.O. Box (if applicable))

City*:     

State*:     Zip*:

Home Phone # *:   

Email Address*:   

AIM:

Religious Affiliation:        Area of Study:

Interests (check all that apply)
 
AIPAC LGBTQA Issues
Arts and Culture Music
Creative Writing Outdoor Programming
Holocaust Commemoration Shabbat
Hebrew Speaking Group Social Action/Justice
Israeli Dancing Social Programming
Interfaith Programming Sports
Israel Theatre
Jewish Learning Women's Issues

I've been to Israel?: Yes  No

I can lead services/read Torah?: Yes  No

I want a mentor?: Yes  No