icnext 11 REGISTRATION FORM

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

ICNEXT 11 REGISTRATION FORM

STUDENT INFORMATION

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Date of Birth*

Answer required for "Date of Birth"

Grade as of September 2022*

Answer required for "Grade as of September 2022"

Student Phone*

Number Required

Student Email*

Answer required for "Student Email"

Student School*

Answer required for "Student School"

Synagogue *

Answer required for "Synagogue "

PARENTS INFORMATION

Parent 1 First Name*

Answer required for "Parent 1 First Name"

Parent 1 Last Name*

Answer required for "Parent 1 Last Name"

Parent 2 First Name*

Answer required for "Parent 2 First Name"

Parent 2 Last Name*

Answer required for "Parent 2 Last Name"

Parent 1 Phone*

Number Required

Parents 2 Phone*

Number Required

Parent 1 Email*

Answer required for "Parent 1 Email"

Parents 2 Email*

Answer required for "Parents 2 Email"

Address*

Answer required for "Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip Code*

Answer required for "Zip Code"

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

Answer required for "In Case of Emergency, Person to Contact (If Not Parents)"

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*

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

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

Answer required for "Have You Been To Israel Before? If Yes, When and With Whom?"

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

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

(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)*

Answer required for "Please List 2 Reference: One Academic and One Personal (Name, Phone and email For Each)"

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