Rodef Shalom Retreat Registration Form

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Rodef Shalom Retreat Registration Form

1. PROGRAM APPLICATION

Thank you for applying to the Rodef Shalom Retreat.

To complete your application you need to:

Fill out the online application form below
Pay the non-refundable minimum deposit of $50 (remaining tuition fee is $150)

For questions about this registration form please contact PCJCR@pardes.org.il

3. CONTACT INFORMATION

Home Phone Number:

Please include full dialing codes

Cell Phone Number

Email address:

Current Address

Current Address Line 1:

Current Address Line 2:

City:

State:

ZIP Code:

Country:

Good until:

DD/MM/YY

Permanent Address

Permanent Address Line 1:

Permanent Address Line 2:

City:

State:

ZIP Code:

Country:

4. EDUCATIONAL & PROFESSIONAL EXPERIENCE

Higher Education

Name of Institution:

Location:

Major/Field of Study:

Degree:

Additional Comments:

Please add extra institutions or educational details here.

Current or Previous Occupation

Position:

Work, student, homemaker, etc.

Employer:

Start Date:

MM/YY

End Date:

MM/YY

5. JEWISH AND CONFLICT RESOLUTION INVOLVEMENT Please complete all relevant sections

List current involvement in conflict resolution organizations (community mediation centers, school mediation programs, interfaith organizations, peacemaking programs, etc.) or in conflict resolution training (mediation, facilitation, academic study, etc.)

Jewish Education

Name of Institution:

Location:

Area of Study:

Level:

Dates:

Comments:

Jewish Summer Camp

Name of Camp:

Location:

Postion:

Year/s Attended:

Comments:

Visits to Israel

Dates:

Duration:

Framework:

Synagogue

Name:

Location:

Rabbi's Name::

Comments:

Which category do you consider yourself a part of? This will be used for break-out sessions during the retreat.

Rabbinic (rabbis and rabbinic students)Conflict resolution professionals (lawyers, mediators, interfaith/political/international-relations organization professionals and lay leaders)Educators (teachers and educators)Academics (Judaic studies and conflict resolution studies)Jewish communcal leaders (professionals and lay leaders)Other

7. PAYMENT

Please make your payment. Your application cannot be processed without payment.

I would like to pay

$200 Full tuition$50 Minimum deposit (balance is due May 1, 2012)

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