First name		Last name
Sex	Male  Female	Birth date
Passport number		Nationality

Street address		City
State / Province		Postal code
Country		Home phone
Work phone		Mobile phone
Email address

Current place of work or study
Job title or name of degree
Previous educational degree(s)
Name of educational institution(s)

Please list any physical or psychological conditions that might affect your participation in the program:
Medical Insurance Carrier and Policy No.:

Emergency contact in Israel:

Full name		Relation to you
Phone number		Email address

Emergency contact at home:

Full name		Relation to you
Phone number		Email address

Have you ever participated in a Ta Shma program?     yes   no

How did you hear about Ta Shma's summer beit midrash?

How do you define yourself Jewishly? (labels, no labels, feel free to be creative!)

Please describe your background in Jewish learning:

Please feel free to share any other questions, comments or requests you may have:

Please register me for the following summer beit midrash session(s):