Apply

Mikdash Melech Jerusalem-Student Application Form

Dear Applicant. Please complete this application to the best of your ability. Please pay attention to the required fields indicated by an asterisk (*). Incomplete applications will not be accepted. If you require any assistance, please call 732-370-6823 or email: mmjerusalem@gmail.com

Student Information

Please upload a recent picture of youself

Last Name (*)

First Name (Legal) (*)

Middle Name

Called Name (If different than the Legal Name)

Hebrew Name (If different than Legal or Called name - use English characters)

Name of School presently atttending (*)

When do you plan on attending? (*)

Home Address (*)

City (*)

State

Zip

Country (*)

Home Phone Number

Cell

Date of Birth (*)

Passport number

Passport Issuing Country

Do you or either one of your parents have an Israeli ID/Passport? (*)

Parent Information

Parents' Marital Status (*)

Father's Title

Father's Last Name (*)

Father's First Name (*)

Father's Cell Number (*)

Father's Email Address (*)

Father's Occupation (*)

Father's Business Name

Mother's Last Name (*)

Mother's First Name (*)

Mother's Cell Number (*)

Mother's Email Address

Mother's Maiden Name

Mother's Occupation

Mother's Business Name

Community

Is any Parent / Grandparent a convert to Judaism? (*)

Congregation in which your parents are members (*)

Rabbi's Name (*)

Rabbi's Contact Information

Have you had any brother/s attend Mikdash Melech? (*)

If yes, please list

Name of the last Elementary School applicant attended & location

Did you attend more than one highschool?

List 2 people (preferably recent Teacher or Rabbi) who can serve as character and educational references for you. Please include phone numbers.(*)

If currently post High School, what are you doing?

Who recommended MMJ to you?

Medical Information

Do you currently have any medical conditions - Physical or emotional that requires medication and/or treatment? (*)

If yes, please describe

List any medications currently taking:

Do you have any food allergies? (*)

If yes, please detail

Additional Information

What is your primay spoken language?

What other languages do you speak?

List Limudei Kodesh course work completed during the most recent School year

List any hobbies or extracurricular activities that interest you

If accepted, What would your prime objective be by attending MMJ? (*)