APPLICATION FOR ADMISSION TO ORCHOS CHAIM

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1.  Name ________________________________________________________________________________________
		last 		          first                                   middle                                     Hebrew
2.  Address ______________________________________________________________________________________
		number & street 		city 		state or country  		zip code
3. Telephone ______________________________  Fax _____________________________
4.  Date of birth ________________ Place of birth _______________________________________________________
		day  / month / year 			city 		        state or country     
5.  Passport No. __________________ Visa Status:  Student  o Tourist o  Other o ___________________________
6.  Marital Status:  Single o Married o   Divorced o  Wife's name _________________________________________
7.  If you or your mother were converted check box o .   Include all available certification with application.
8.  Father's name __________________________________    Mother's name __________________________________  
     Occupation ____________________________________    Occupation ____________________________________
     Employer's name________________________________    Employer's name________________________________
     Business Telephone _____________________________     Business Telephone _____________________________
9.  People to contact in case of emergency:  
     Outside of Israel ________________________________________________________________________________
      			name 			     address 			    telephone 
      Inside of Israel _________________________________________________________________________________ 
			name 			     address			    telephone 
10.  Do you have medical insurance?  Yes o No o  
11.  Do you have any medical conditions? Yes o  No o  If yes, please list ____________________________________
________________________________________________________________________________________________
12.  Are you taking any medications?  Yes o No o  If yes, please list _______________________________________
________________________________________________________________________________________________
13.  Have you ever been treated for or do you carry any serious physical disorders?  Yes o  No  o  
       If yes, please list______________________________________________________________________________
14.  Have you ever been treated for any mental disorders?  Yes o Noo                                                        
        If yes, please explain___________________________________________________________________________

15.  Post High School education: 
 1)   Name___________________________________  Location ___________________________________________
								city                           state or country   
       Years attended _______________  Degree ________________________________
 2)  Name___________________________________  Location ____________________________________________
								city                          state or country   
       Years attended _______________  Degree ________________________________
16.  Jewish education: 
 1)  Name___________________________________  Location ____________________________________________
								city                           state or country   
       Years attended _______________  
 2)  Name___________________________________  Location ____________________________________________
								city                           state or country   
       Years attended _______________  
      Knowledge of Hebrew:       Reading:     Fluent o    Fair o    None o  
                                                   Writing:      Fluent o    Fair o    None o  
                                                   Speaking:    Fluent o     Fairo    None o  
17.  If employed, who was your last employer?  Name____________________________________________________
       Location _________________________________________  Position____________________________________
		city                                      state or country   
18.  How did you hear about Orchos Chaim? ___________________________________________________________
19.  Why do you want to attend Orchos Chaim?_________________________________________________________
________________________________________________________________________________________________
 20.  Additional comments: _________________________________________________________________________
________________________________________________________________________________________________

    
	__________________			____________________________________
		Date 						Signature


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Please send application,  one wallet size picture, one recommendation (if possible), and a $50 application fee to:                            Orchos Chaim, 27/1 HaRav Sorotzkin Street, Jerusalem, Israel  94423 or American Friends of Orchos Chaim, c/o Rabbi Shimon Russell, 324 Carey St., Lakewood, N.J.  08701.

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