Permanent address:
City: State: ZIP:

Cell phone: Email:

College/University:
Current year in school: Major(s):

On-campus address:
City: State: ZIP:

Place of birth: Date of birth (mo/day/year):

Please list your current and previous leadership positions and involvement in
on-campus organizations that you belong(ed) to:

Describe your involvement in campus organizations. If you coordinated any programs, provide details about the program(s) and your specific role(s) in organizing those events.

Describe your upbringing. List schools, camps, groups, etc. that you attended/belonged to.

Please list the times you have been in Israel. Include the dates, duration of stay, and purpose of visit. Also please list organizations that sponsored program(s) you attended (if applicable) and relevant experiences (e.g. synagogue trip, youth group program, Birthright Israel, etc.).

How do you plan on being involved with the Zionist community on campus next year? Are you interested in being a ZOA representative on your campus?

Please list two references
(Name, phone number, email, position and relationship):