ICNEXT 15 APPLICATION FORM

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

ICNEXT 15 APPLICATION FORM

PART 01 - SHOULD BE FILLED OUT BY THE STUDENT

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 2026*

Answer required for "Grade as of September 2026"

10th Grade

11th Grade

Other:

Gender*

Answer required for "Gender"

Male

Female

Other:

Student Phone*

Number Required

Student Email*

Answer required for "Student Email"

Student School*

Answer required for "Student School"

Shirt Size*

Answer required for "Shirt Size"

XXL

Please describe your extracurricular activities. Please be sure to include any Israel-related activities as well.*

Answer required for "Please describe your extracurricular activities. Please be sure to include any Israel-related activities as well."

Have you been to Israel before? If yes, please list when you were there and what type of trip it was (i.e. day school, family trip, etc.)*

Answer required for "Have you been to Israel before? If yes, please list when you were there and what type of trip it was (i.e. day school, family trip, etc.)"

Essay Questions - Please select one of the questions and answer in 100-150 words in the box below. Please indicate which question you are answering at the top of your essay (not included in the word count)

Option 1: icnext is not just a trip to Israel. It is a two year commitment that includes 8 pre-trip sessions, a mission to Israel, and a year two fellowship. Why would you like to participate in this program?

Option 2: As a Jewish teen in Cleveland, what does your relationship with Israel look like today? Feel free to share positive and/or challenging experiences.

Your Answer*

Answer required for "Your Answer"

Academic Reference - please list name, relationship to participant, and reference email*

Answer required for "Academic Reference - please list name, relationship to participant, and reference email"

Personal Reference - please list name, relationship to participant, and reference email

Answer required for "Personal Reference - please list name, relationship to participant, and reference email"

PART 02- SHOULD BE FILLED OUT BY PARENT

IMPORTANT MEDICAL INFORMATION (Allergies, prescriptions, illness presently under physician's care, etc.)

HEATH INSURANCE CARD 01 - Please upload image or pdf copy of the student Health Insurance (card front)*

Answer required for "HEATH INSURANCE CARD 01 - Please upload image or pdf copy of the student Health Insurance (card front)"

Choose a file or drag it here.

HEATH INSURANCE CARD 02 - Please upload image or pdf copy of the student Health Insurance (card back)*

Answer required for "HEATH INSURANCE CARD 02 - Please upload image or pdf copy of the student Health Insurance (card back)"

Choose a file or drag it here.

Describe any health-related concerns (e.g. heart problems, diabetes, etc.):

Answer required for "Describe any health-related concerns (e.g. heart problems, diabetes, etc.):"

Medication Responsibility. Please select one:*

Answer required for "Medication Responsibility. Please select one:"

My child does not take any medication

My child will carry and self-administer their medication

I give permission for staff to hold and administer my child’s medication as needed

Current Medications: Please list all medications your participant is currently taking. Include: Medication name Dosage Frequency (e.g., once daily, as needed) Administration instructions (e.g., with food, time of day, etc.)

Answer required for " Current Medications: Please list all medications your participant is currently taking. Include: Medication name Dosage Frequency (e.g., once daily, as needed) Administration instructions (e.g., with food, time of day, etc.)"

Dietary Requirements - All meals provided will be kosher-style. As local catering options are limited, if your child requires strictly kosher (hechshered/sealed) meals, please contact Sydney Milgrom*

Answer required for "Dietary Requirements - All meals provided will be kosher-style. As local catering options are limited, if your child requires strictly kosher (hechshered/sealed) meals, please contact Sydney Milgrom"

None

Vegetarian

Vegan

Gluten-free

Dairy-free

Other:

Are there any learning needs, accommodations, or supports that would help us create the best experience for your teen?

Answer required for "Are there any learning needs, accommodations, or supports that would help us create the best experience for your teen?"

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 1 Phone*

Number Required

Parent 1 Email*

Answer required for "Parent 1 Email"

Parent 2 First Name

Answer required for "Parent 2 First Name"

Parent 2 Last Name

Answer required for "Parent 2 Last Name"

Parent 2 Phone

Number Required

Parent 2 Email

Answer required for "Parent 2 Email"

Address*

Answer required for "Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip Code*

Answer required for "Zip Code"

ADDITIONAL INFORMATION

Non-Parent Emergency Contact Name*

Answer required for "Non-Parent Emergency Contact Name"

Non-Parent Emergency Contact Relationship to Participant *

Answer required for "Non-Parent Emergency Contact Relationship to Participant "

Non-Parent Emergency Contact Phone Number*

Number Required

I plan to use the following payment method:*

Answer required for "I plan to use the following payment method:"

Credit Card

Check

PARENT OR GUARDIAN SIGNATURE

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

ICNEXT 15 APPLICATION FORM