Instructions: Please answer all questions. Inapplicable items should be marked N/A. Step 1 of 5 20% Contact InformationName* First Last Preferred Name First Last Hebrew Name (including your surname) - in Hebrew Email* Home Phone*Cell PhonePlace of Birth Birthdate* MM slash DD slash YYYY Full legal name on passport First Last Passport Number Passport Expiration Date MM slash DD slash YYYY Do you have an Israeli citizenshipYesNoDo you have an Israeli passportYesNoCountry Issuing Passport Teudat Zehut (If Israeli Citizen)Shul Shul Rabbi Iyun Rebbe Iyun Rebbe's phone numberBekius Rebbe Bekius Rebbe's phone numberMailing Address Type--None--BusinessPrimary HomeSecondary HomeSchoolPO BoxOtherAddress* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Current SchoolProposed start and end dates of studyHow did you hear about us?What interests you in Bircas?What are your interests/ extracurricular activities?What did you do the past two summers?What are your plans for this coming summer?Please select your level of learning–None–Don't know, I haven’t learnt gemorra yet½ Amud just gemorra (with translation help)½ Amud Rashi (with translation help)Amud Rashi/TosfosDaf Rashi TosfosAmud with RishonimHow long have you been learning & whereDo you have any learning disabilities? Do you/have you had medical conditions? Are you currently taking any medication? If yes, please explain. Have you ever had an assessment? (e.g. Cognitive and Academic Assessments, Social-Emotional Assessments, Special Education and Disability Assessments, College and Career Readiness Assessments)*NoYesPlease explain what assessment was taken and why. Parents InformationFatherFather's Last Name Father's First Name Father's TitleNoneMr.Dr.RabbiFathers Date of Birth MM slash DD slash YYYY Fathers Home AddressFathers Occupation Fathers Business PhoneFathers Cell PhoneFathers Email MotherMother’s Last Name Mother’s First Name Mother’s Maiden Name Mothers Date of Birth MM slash DD slash YYYY Mothers Home AddressMothers Occupation Mothers Business PhoneMothers Cell PhoneMothers Email Was your biological mother born Jewish?* Yes No Was your biological maternal grandmother born Jewish?* Yes No Did you, your mother, or your maternal grandmother convert to Judaism?* Yes No Please check who converted You Your mother Your maternal grandmother Please attach a copy of the conversion documents to your application* Drop files here or Select files Max. file size: 512 MB. Tuition Contact PersonPlease provide contact information of the contact person for tuition arrangements.Name* Relationship to you* PhoneEmail* ReferencesReference 1Name* (your rav if possible)Occupation* Relationship to you* Phone*Email* Reference 2Name* Occupation* Relationship to you* Phone*Email* Emergency ContactPlease provide contact information of someone that we can reach out to in in case of an emergency.Emergency Contact Name Relationship to you Home PhoneCell Phone Please have a copy of your latest High School transcript sent to us by the school directly.Upload TranscriptAccepted file types: doc, docx, pdf, txt, rtf, Max. file size: 512 MB. Please upload a clear picture of yourself (a headshot).Photo upload*Accepted file types: jpg, jpeg, gif, png, Max. file size: 512 MB.* "I have read and understand the fee schedule." CAPTCHAList PhoneThis field is for validation purposes and should be left unchanged.
