The Derek Israel Memorial Scholarship Fund - Jewish Federation of ...

300 Grand Avenue Oakland, CA 94610ph. 510-318-6411 f. 510-839-3996 jessi@jfed.orgThe Derek Israel Memorial Scholarship FundApplicable for Yeshiva Study in Israel;DEADLINE FOR REVIEW:Friday, September 14, 2012—for Fall and Winter-season programsFriday, December 7, 2012—for Winter and Spring-season programsFriday, March 8, 2013—for Summer programsFriday, May 17, 2013—for Summer and Fall-season programsAbout the Fund: The Fund was set up by friends and family in memory of Derek Israel, ofblessed memory, who died tragically at Sears Point Raceway in 1997. Derek was a young carracing enthusiast who also passionate about Torah study and the land of Israel. The fund in hishonor provides young adults with the opportunity to study at Orthodox Jewish institutions inIsrael, in Derek’s memory. The Derek Israel Memorial Scholarship Fund is housed at TheJewish Community Foundation in Oakland. All applications are anonymously and confidentiallyreviewed by committee process.ELGIBILTY:Eligibility: The Derek Israel Memorial Scholarship Fund awards East Bay young adults age 21and over to attend programs of study at Orthodox Jewish institutions in Israel.Eligible Programs: For a comprehensive list of eligible Orthodox learning centers in Israel,please visit http://www.science.co.il/yeshivot.aspResidency Requirements: Applicants who have a permanent residence in the East Bay(Alameda, Contra Costa, Napa, and Solano counties).Financial Statement of Need:Independents: Individuals who claim financial independence from their parents or guardiansmust submit the first two pages of their own most recently submitted federal tax return.Students who are financially dependent on their parents must submit the first two pages oftheir parent/guardian’s most recently submitted federal tax return.APPLICATIONS SUBMITTED WITHOUT FEDERAL TAX FORMS WILL NOT BE CONSIDERED.Send your completed application form and tax returns to:Derek Israel Memorial Scholarship ProgramAttn: Program OfficerThe Jewish Community Foundation300 Grand AvenueOakland, CA 94610Questions? Contact Jessi Norris at 510-318-6411 or jessi@jfed.org

300 Grand Avenue Oakland, CA 94610ph. 510-318-6411 f. 510-839-3996 jessi@jfed.orgThe Derek Israel Memorial Scholarship FundApplicants Information Form 1Applicant’s name:Date of birth: Female MaleAddress:City, State, Zip code:Home Phone:Mobile Phone:Email:Synagogue and Location (if affiliated):Other Jewish involvement (please list):Parent/Guardian information (if applicant is financially dependapplicable)Parent/Guardian name:Address: (if different than applicant)City, State, Zip code:Home Phone:Mobile Phone:Email:Have you ever been to Israel before? Yes NoIf yes, please state the program or purpose of your trip (i.e. Birthright, with family, etc. —state the name ofthe program, be specific)Dates and duration of previous program or trip(s):Have you or anyone your household applied for a Jewish Community Foundation scholarship?Yes NoProgram name and dates of program:Amount awarded by Jewish Community Foundation: $Please list one personal Jewish reference (Rabbi, teachers etc.)Name:Phone:Relationship:Email:Derek Israel Memorial Scholarship Application: Page 1 of 3

300 Grand Avenue Oakland, CA 94610ph. 510-318-6411 f. 510-839-3996 jessi@jfed.orgThe Derek Israel Memorial Scholarship FundProgram Information and Cost Form 2Information on Yeshiva program and funding sourcesName of intended school/yeshiva in Israel:Dates of intended school/yeshiva program:Complete contact information for program: (must include name, address, phone, e-mail,website)1. PROGRAM COST: Cost $Cost of flight: Flight $2. WHAT COST WILL YOU COVER? The Derek Israel Memorial Scholarship Fundexpects applicants to contribute to the cost of the trip.a. Applicant/Family’s contribution (including relatives and friends) $b. Other scholarship or financial aid award(s) Please list: $c. Funding from synagogue∗ $d. Total applicant/family contribution (add Lines 2a through 2c) $3. TOTAL FINANCIAL ASSISTANCE REQUESTED (subtract Line 2d from Line 1)$∗ (We encourage applicants to approach synagogues or rabbis for scholarship or discretionary fundingconsideration.)4. IS THE APPLICANT FINANCIALLY INDEPENDENT, OR DEPENDENT?[ ] Dependent [ ] IndependentIf dependent, list parent’s gross Income 2011and submit parent’s federal tax statementIf independent, list applicant’s gross Income 2011and submit applicant’s federal tax statement$_________$_________Derek Israel Memorial Scholarship Application: Page 2 of 3

300 Grand Avenue Oakland, CA 94610ph. 510-318-6411 f. 510-839-3996 jessi@jfed.orgFinancial Need and Personal Statement Form 31. Financial Need: Please indicate why you are applying for financial aid to study inIsrael. Include any circumstances (family or individual) that the committee should know.Please indicate how you intend to pay for this program if the Derek Israel MemorialScholarship is not awarded. This statement may be attached and should not exceedone page in length.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. Statement of Intent: Please summarize what has motivated you to participate in aprogram of Orthodox study in Israel. Include your previous and current involvement withthe Jewish community, your plans for study in Israel, and specific ways that you hope tocontribute to the East Bay Jewish community upon your return as a Derek IsraelScholar. This statement may be attached and should not exceed one page in length.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Applicant’s Signature SSN# DateDerek Israel Memorial Scholarship Application: Page 3 of 3