I cannot attend but would like to be on mailing list

A. Personal Information:

First and Last Names Hebrew Name Spouse's Hebrew/English Name Address City State Zip Country

Phone Fax Email Work Phone Cell Phone Screen Name

Maritial status Single Married Divorced Widowed Age

Your Date of Birth Your Date of Birth (hebrew) Your Spouse's Date of Birth Your Spouse's Date of Birth (hebrew)

Mother's Hebrew Name Mother's Name Address City State Zip Phone Number

Father's Hebrew Name Father's Name Address City State Zip Phone Number

In case of an emergency please contact:
Name: Phone: Relation:	Name: Phone: Relation:

Number of Children Are you interested in child care, or chldren's programs while participating in our programs? No Yes

Child's Name Age School Date of Birth Interests 1. 2. 3. 4. 5. 6.

Highest Grade Completed:
Elementary Some High School High School	College Some College Certificate	BA, BS MA, MS PHD

Please list all institutions attended, location, degree achieved and the field of study.

Institution (Jewish & Secular) Location Highest Grade Completed Major 1. 2. 3. 4.

Professional Training Current Occupation	Spouse's Professional Training Spouse's Current Occupation
Would you like to utilize your skills within Machon Chana environment? No Yes

B. General Information:

Interest, hobbies:

What kind of workshops would you like to see on our program:

C. Jewish Background:

Are you observant? Yes No
Describe your level of observance and for how long:

Are you a convert to Judaism? Yes No
What is your most positive Jewish experience?

What is your most negative Jewish experience?

What is your general view of the Lubavitch movement?

Jewish contact & referrals (Rabbis, Shliach, or a head of Jewish organization that knows you well)

Name	Phone	Relation
1.
2.
3.
4.

In what kind of programs would you like to participate in the future?

Shabbatons (weekend seminars) Summer Programs Banquets Fundraising Evening Lectures Day Long Seminars Summer Women's YeshivaCation (week long) Winter Women's YeshivaCation (week long) Kollels (programs for couples & families) Conventions Other, please explain:

What would you be most interested in learning?

Kabbalah Family Issues Education Relationships Prophets Hebrew Language Yiddish Language Moshiach Secrets of Torah Chassidus (Jewish philosophy) Tanach (Bible text) Tanya (Jewish psychology) Jewish Law Midrash/Talmud Other, please explain:

What is your knowledge of the following subjects: On a scale of 0-3
0- No prior knowledge
1- Beginners
2- Intermediate
3- Advanced

A. Reading

Hebrew Reading
Do you know how to Daven?
Do you read Yiddish?
Do you read Rashi?

B. Chassidus

Tanya
Sichos (discourses of the Rebbeim)

C. Jewish Law

1. Laws of Shabbos

a. 39 Melachos
b. Kiddush & Havdalah
c. Muktza
d. Shabbos Preparation

2. Laws of Kashrus

a. Separation of Milk and Meat
b. Identifying Reliable Hechsherim
c. Immersion and Kashering of Vessels

B. Textual Studies

Chumash
Navi
Rashi
Hebrew Grammar
Biblical commentaries
General Hebrew text (knowledge of grammar)

What is your first language?
What other languages do you speak fluently?

Please add any additional information you feel we should know about you.

C. Financial Information:

Are you able to pay the full amount for our programs? Yes No

Approximate annual household income:

Would you like to make a donation? Yes No

If yes, what is the best way to bill you? Cash Check Visa Discover MasterCard

Disclaimer: All information is kept strictly confidential in our database. By submitting below you verify that all information stated above is true to the best of your knowledge. Any misjudged information will not help us serve you better.

For more information and to request a brochure by mail you can either e-mail Rochie at YVC@machonchana.org or call (718) 735-0030.