icnext 11 REGISTRATION FORM

Please complete the form below. Required fields marked with an asterisk *

ICNEXT 11 REGISTRATION FORM

STUDENT INFORMATION

First Name*

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Last Name*

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Date of Birth*

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Grade as of September 2022*

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Student Phone*

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Student Email*

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Student School*

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Synagogue *

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PARENTS INFORMATION

Parent 1 First Name*

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Parent 1 Last Name*

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Parent 2 First Name*

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Parent 2 Last Name*

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Parent 1 Phone*

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Parents 2 Phone*

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Parent 1 Email*

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Parents 2 Email*

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Address*

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City*

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State*

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Zip Code*

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In Case of Emergency, Person to Contact (If Not Parents)*

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EXTRA CURRICULUM

List Your Extracurricular Activities. Include and Describe Your participation In Pro-Israel Activities In Your Community, At Your School, Youth Movement Or Synagogue*

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Have You Been To Israel Before? If Yes, When and With Whom?

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Are You Currently Writing For Your School Or Community Newspaper? If Yes, Please Paste Sample Here (or attached a file bellow):

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(If needed) Upload pdf scanned copy of Written Sample

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Choose a file or drag it here.

Please List 2 Reference: One Academic and One Personal (Name, Phone and email For Each)*

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ICNEXT 11 TENTATIVE SCHEDULE

1. October 20, 2022 - Participants/Parents meeting
2. October 30, 2022 - Seminar 1
3. November 13, 2022- Seminar 2 and College Visit (TBA)
4. December 4, 2022 - Seminar 3
5. January 8, 2023 - Seminar 4
6. February 5, 2023 - Seminar 5
7. March 5, 2023 - Seminar 6
8. April 16, 2023 - Seminar 7
9. May 14, 2023 - Seminar 8
10. June 11-22, 2023 - Israel Mission
11. September 2023 to May 2024 - Fellowship Work

Please fix the highlighted areas below before submitting.

icnext 11 REGISTRATION FORM