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

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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
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