icnext 12 REGISTRATION FORM

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ICNEXT 12 REGISTRATION FORM

STUDENT INFORMATION

First Name*

Answer required for "First Name"

Last Name*

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Date of Birth*

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Grade as of September 2023*

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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*

Number Required

Parents 2 Phone*

Number Required

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*

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?

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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 12 REGISTRATION FORM