Application Form

Please fill out the form below if you are interested in enrolling in the Mishpacha program. This information will help us select a diverse group of participants and deliver a course that best meets your needs. Your information will be kept confidential.

Tell us about yourself:

Name
City	State
Country
E-mail
Phone #
Your sex:	Male Female
Your age
Highest level of education
Your occupation

Please tell us about your family

Your marital status:
Will your spouse be participating too? Yes No
How many children do you have	Age of oldest? Age of youngest?

Please tell us about your Jewish background

My Jewish schooling:
Do you belong to a synagogue? No Yes
How connected are you to your local Jewish community?

Please tell us about your computer

Your computer runs:
Macintosh Windows 3.1 Windows 95 Other

Please add anything else you want to tell us about yourself, your Jewish background, and what you would like to get out of the Mishpacha program

Please tell us how you heard about Mishpacha

Which specific site/newspaper/etc.?

Mishpacha is Hebrew for "family". So don't be a stranger: Send your comments to mishpacha@e-moses.com
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