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Yeshiva Bais Menachem (RAP) Application Form

Please be sure to read and fill out this application form in its entirety. This application must be submitted with a $300 non refundable application fee. Please be aware that applications will not be processed if not filled out completely or without the application fee.

Program Information: The program begins after Tishrey around Rosh Chodesh Cheshvon and goes till right before Gimmel Tammuz.

Tuition: Tuition for the program is $15,000 (limited scholarships available). Tuition includes all costs involved with learning, boarding, food and activities. Tuition does not inclue flight and health insurance.

Personal Information

Students Full Name

Students Hebrew Name

Students Date of Birth

Students Hebrew Date of Birth

Students Fathers Name

Students Mothers Name

Parents Marital Status

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Students Cell Phone Number

Students Email Address

Fathers Cell Phone Number

Fathers Email Address

Mothers Cell Phone Number

Mothers Email Address

Please list students siblings if previously attended our Yeshiva:

Travel and Medical Info

Students Passport Number

Students Nationality

Emergency Contact Overseas (name, phone number)

Emergency Contact in Israel (name, phone number)

Medical History (allergies and other medical condition)

Please be advised that all students must have medical insurance prior to arriving to Yeshiva. More information will be sent closer to departure time

are you receiving psychological treatment and/or counseling or have you in the past?

Yes

Are you currently taking any medications? If yes please list:

Education Info

Mesivta/High School Attended:

Zal/Bais Medrash Attended

Please rate your Hebrew language skills:

List students special skills or interest’s:

Please list two references (names & phone numbers) below whom we may contact.

Signatures

Students Signature

Parents signature

Payment Details

Application Fee

Price:

Credit Card

American Express

Discover

MasterCard

Visa

Total