Los Angeles Diller Teen Fellows
application
2011-2012
Applications Accepted untilWednesday, August 31, 2011

Return this completed applicationelectronically (preferred!)to , fax to323-954-9175 or mail to:Stephanie Kane, Westside JCC, 5870 W. Olympic Blvd., Los Angeles, CA 90036 Tel: 310-556-5215

(To be filled out by applicant – no handwritten applications will be accepted)

I. General Information

First name______Last name______

Address CityZip

Phone number (Cell) Phone number (Home)

E-mail Birth date Male/Female

Family Information:

Parent name / Address / Daytime phone / Evening phone / e-mail

Parents are: Married Divorced Separated Other _____

Siblings: number: Names and ages:______

Applicant lives with: Both parents Mother Father Shared Custody Other

Are you a U.S. citizen? Yes No

If not, what is your immigration status? (Refugee, Green Card, etc.)

2011– 2012 Los Angeles Diller Teen Fellows Program ApplicationPage 1

One or both of my parents is/are either Israeli-born or Israeli Citizen(s).

I have dual citizenship Israeli/American

Religious Affiliation (Check One)

Orthodox Conservative Reform Reconstructionist Secularist Just Jewish

Other (please explain)______

Synagogue Affiliation(if applicable)

Name/Location:

Dietary Requirements/Preferences: No Requirements/Preferences Vegetarian

Kosher (do NOT separate meat & milk dishes) Kosher (do separate meat & milkdishes)

Other, please explain:

II. Education

High School

School name/location

/

Graduation date

Jewish Education

Synagogue name/Jewish day school/location

/

Dates from-to (mo./yr.)

Supplemental Education (Hebrew High, after school classes in Judaica/Hebrew, etc.)

/

Dates from-to (mo./yr.)

Private Bat/Bar Mitzvah Training

/

Dates from-to (mo./yr.)

No Jewish Religious Education of any kind—check box

Camp and Youth Group Participation (please list any experience you have had as a camper or a youth group member)

Institution name/location

/

Dates from-to (mo./yr.)

Leadership Experiences (please list all positions you have held as a camp counselor, teacher, youth group board member, school government, clubs, etc. both in the Jewish and secular communities)

Position / Institution name/location / Ages worked with
(if applicable) / Dates from-to
(Mo./yr.)

Extracurricular Activities (list hobbies, awards, clubs, organizations, skills, honors received, and any and all special interests)

Previous Travel Experiences

United States/Canada:

Israel (please list family trip or type of program, sponsoring organization, length of time and dates attended):

Abroad (other than Israel):

Previous volunteer/community service experience:

What excites you most regarding the opportunity to be a Diller Teen Fellow? ______

______

______

What aspects of Jewish life do you connect with most strongly?

______

______

______

______

What other commitments (Clubs, youthgroups, music, sports, family or others) have you made that could potentially conflict with this program’s workshops and activities? Please include approximate time(s) per week/month as well.

______

______

______

Please take a few minutes to complete each of the statements below

a) I would describe myself as______

b) People think that I am______

c) I am committed to the cause of______

d) I admire because

e) Before I am 75, I would like to______

III.References(Two required)

The references should be fromnon-relatedadults who can attest to your character and leadership skills. Personal friends are also not acceptable. One letter must be from a school official or teacher. The references you list must complete a response form posted with this packet, or a separate letter of reference on their letterhead.

References may be sent electronically, to the following email address: orfaxed/mailed to the address at the top of this application.

NOTE: You DO NOT need to wait for these reference forms to mail in your application!

Name/full address of persons to provide reference / daytime phone / Relationship

IV. Parents’ Permission(Please sign and mail original to:Stephanie Kane, Westside JCC 5870 W. Olympic Blvd, Los Angeles, CA 90036 or Fax: 323-954-9175

I,______, give permission for

(Name of parent or legal guardian)

My child,______, to participate in the

(Name of applicant)

Los Angeles Diller Teen Fellows program, a project funded by the Helen Diller Family Foundation and The Jewish Federation of Greater Los Angeles.

Signature of parent or legal guardianDate

Signature of applicantDate

Name of applicantDate

I certify that all statements and details in this application are accurate and correct:

Applicant’s Signature ______Date ______

I would like to be considered for financial aid. Yes ______No ______

PLEASE- reread your application, and make sure it is completed in its entirety before submitting.

Please mail or e-mail a photo of yourself (make sure it is a photo of you only).

An incomplete application may result in your disqualification from the program.

Have more questions?

Our website is click on the youth programs/diller.

Please feel free to call Stephanie Kane 323-556-5215or e-mail with any questions. Remember, NOW is the time to apply.

An application is not complete without all of the following: A completed application form, a photo of yourself (alone), two references and the parent’s permission page signed by you and your parent(s), although you need not wait for your references and your parent’s form to submit your application

The Application Period is open through Wednesday, August 31, 2011 at 5PM PDT