Montreal Diller Teen Fellows Application 2011 - 2012

General Information (1/8)

Family Name: *

First Name: *

Address: *

Mailing Address, City, Province, Postal Code

Home Phone Number: *

Cell Phone Number:

E-mail Address: *

Sex: *

male

female

Birthdate: *

Age as of June 1, 2012: * years

School Presently Attending: *

Grade: *

Medicare Number and Expiry Date: *

Allergies:

Should more information be required, a Diller Representative will contact you

Do you carry an EPI-pen?:

yes

Dietary Requirements/Preferences:

Kosher

Vegetarian

Other, please explain

Please tell us how you heard about the Diller Teen Fellows: *

School

Ad/Internet

Family Member

Friend (please specify who) or any other way (please specify)

Please submit a recent photo of yourself.: *

.gif .jpg .png accepted. Max. filesize 2MB.

Family Information (2/8)

Parents are: *

Married

Divorced

Separated

Other

First Parent/Guardian

Parent/Guardian Name: *

Relationship to Applicant: *

Address: *

Home Phone Number: *

Cell Number:

Email Address: *

Second Parent/Guardian

Parent/Guardian Name:

Relationship to Applicant:

Address:

Home Phone Number:

Cell Number:

Email Address:

Emergency Contact

Emergency Contact Name: *

Relationship to Applicant: *

Address: *

Home Phone Number: *

Cell Number:

Email Address:

Number of Siblings:

Names & Ages of Siblings:

About the Applicant (3/8)

Are you a Canadian Citizen?: *

yes

Are one or both of your parents Israeli-born or Israeli Citizen(s)?: *

yes

List any extracurricular activities, hobbies, awards, clubs, organizations, skills, honors received, and special interests that you might have.: *

Synagogue Affiliation (if applicable):

Name & Location

Jewish Education (if applicable)

Synagogue Name / Jewish Day School / Location:

Dates: from-to (Month / Year):

Camp and Youth Group Participation

Please list any experience you may have had as a camper or a youth group member.

Institution Name / Location:

Dates: from-to (Month / Year):

Leadership Experience

Please list any leadership experience you might have. Please list any positions you have held as a camp counselor, teacher, youth group board member, etc. - both in the Jewish and secular communities.

Position:

Institution Name/Location:

Kids' Ages:

Dates: from-to (M/Y):

Previous Travel Experiences (4/8)

Have you ever been outside Canada?: *

yes

Have you ever been outside North America?: *

yes

Have you ever been on an organized group tour/trip?: *

yes

Have you ever been to Israel?: *

yes

If Yes, please list the type of trip / program, sponsoring organization, length of time and dates attended and any other relevant information:

Have you ever traveled abroad (other than Israel)?: *

yes

If Yes, please list the type of trip / program, sponsoring organization, length of time and dates attended and any other relevant information:

Some General Questions (5/8)

What excites you most regarding the opportunity to be a Diller Teen Fellow?: *

What aspects of Jewish life do you connect with most strongly?: *

What other commitments have you made that could potentially conflict with this program? Please include approximate time per week:

Please take a few minutes to complete each of the statements below

I would describe myself as: *

People think that I am: *

I am committed to the cause of: *

I admire _________________________ because: *

Before I am 75, I would like to: *

Tell us briefly what you would like to gain out of this program: *

Letters of Reference (6/8)

In addition to your application, please submit TWO letters of recommendation. These letters should come from non-related adults who can attest to your character, leadership skills and experience. Personal family friends are also not acceptable. One letter must be from a school official or teacher.

The references you list must complete a response form, which can be downloaded here.

References may be sent electronically, to the following email address: diller@ymywha.com or mailed to:
5400 Westbury Avenue
Montreal, Quebec H3W 2W8

NOTE: You do not need to wait for your reference letters to submit your application**

Please list the adults you have asked to act as a reference

Reference 2

Name: *

Phone: *

Relationship to Applicant: *

E-mail Address:

Reference 1

Name: *

Phone: *

Relationship to Applicant: *

E-mail Address:

Parent’s/Guardians’ Permission (7/8)

Please download this permission form and submit it electronically to the following email address: diller@ymywha.com

or mail to:
5400 Westbury Avenue
Montreal, Quebec H3W 2W8

Final Submission (8/8)

Important Dates on the 2011-2012 Diller Calendar:

North American Seminar (Israelis in Montreal): March 22 – April 2, 2012
Israel Summer Seminar (Montreal Teens in Israel): July 17, 2012 – August 7, 2012

Please reread your application and make sure it is completed in its entirety before submitting.

An incomplete application may result in your disqualification from the program.

Questions? That's why we are here? Call us at (514) 737-6551 ext. 541 or

E-Mail diller@ymywha.com with any questions.

I certify that all statements and details in this application are accurate and correct.

Montreal Diller Teen Fellows Application 2011 - 2012

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