Initial Action Sheet Aliyah Department

CHECK LIST FOR YOUR USE: 1. Application completed 2. Medical form completed 3. Two letters of recommendation 4. $350 USD registration fee due with application 5. The signed last page of the MASA grant (if you are applying for one masaisrael.org) v Keep one copy of your application and this booklet for your records. v There will be a $20 charge for each returned check. ______

Dear Applicant, We are pleased to give you further details of our kibbutz programs. Please read the information and instructions carefully. When our office receives your application, we will make every effort to place you in a program that will meet your requirements.

______HOW TO APPLY 1. Send us the following: a. Your completed Kibbutz Program Application. b. Your medical form completed by you and your physician. c. Two letters of character reference (by an employer, teacher, coach, minister of faith, or someone of similar standing). d. A $350 registration fee (this is NOT an additional fee, but counts towards program cost)

2. In certain cases additional documentation or evaluation may be required. 3. Your application procedures should be completed at least four weeks prior to your desired departure date. Acceptance will not be given until all the documents have been received. 4. The Programs Director will call/email you upon receiving your application. If your application is accepted we will send you an acceptance letter. ______REFUND POLICY Registration fee For all programs, registration fee is not refundable. Program fee You will receive an acceptance packet once you have been accepted to the program and the entire fee is due 4 weeks before the start date. If you cancel after receiving your acceptance but before the start date, you will receive your payment back, minus $850. If you cancel within the first two weeks, you will receive your payment back, minus $1350. After two weeks of program start, no refunds are available. Participants asked to leave the kibbutz are not entitled to any refund.

Kibbutz Program Center, 114 West 26th St. Suite 1004., New York, NY 10001 Telephone: 212-462-2764 Fax:212-675-7685 [email protected] ______

Kibbutz Program Center, 114 West 26th St. Suite 1004., New York, NY 10001 Telephone: 212-462-2764 Fax:212-675-7685 [email protected] DATE:______Kibbutz Ulpan Application

LAST NAME FIRST NAME

DATE OF BIRTH

PASSPORT NUMBER

GENDER

MARITAL STATUS

NATIONALITY COUNTRY OF BIRTH

HEBREW LEVEL RELIGIOUS AFFILIATION

OCCUPATION HIGHEST DEGREE

ADDRESS CITY, STATE ZIP CODE

HOME PHONE CELLULAR

PERMANENT E-MAIL ADDRESS HOW DID YOU HEAR ABOUT OUR 1. family/friends 2. KPC alumni 3. MASA 4. Jewish PROGRAM? Federation/JCC/Synagogue 5. Internet search 6. Newsletter 7. Facebook 8. Other ______EMERGENCY CONTACT PERSON AND PHONE NUMBER DESIRED KIBBUTZ (YAGUR OR 1. SDE ELIYAHU) AND DESIRED 2. START DATE OF PROGRAM 3.

Kibbutz Program Center, 114 West 26th St. Suite 1004., New York, NY 10001 Telephone: 212-462-2764 Fax:212-675-7685 [email protected] COMMITMENT I will stay, work and study Hebrew for the entire term of the program. I understand that I may be transferred to another kibbutz if the original kibbutz to which I have been accepted cancels its program. I understand and agree that in case I do not live up to these commitments, or if I am found unsuitable by the kibbutz, the kibbutz has the right to ask me to leave without assuming responsibility for any additional expenses incurred. I certify that all the information in this application is correct to the best of my knowledge.

______Signature of Applicant ______Signature of parent or guardian (required if applicant if under age 18) ______Date

After completing the form please fax it to 212-675-7685 or E-mail it to [email protected]

Kibbutz Program Center, 114 West 26th St. Suite 1004., New York, NY 10001 Telephone: 212-462-2764 Fax:212-675-7685 [email protected]