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MASSA Scholarship Application

At Congregation Beth Israel and Temple Beth Or, we don’t want a lack of funds to keep students from experiencing the MASSA Israel Program. Information provided in this application is confidential and will not be used for other purposes. Congregation Beth Israel and Temple Beth Or do not discriminate on the basis of race or gender. If you have any questions, please contact Victoria Mayers at Congregation Beth Israel and/or Rabbi Rachel Kort at Temple Beth Or.

Scholarship applicants must first register for the MASSA Israel Program.

* Student's name:

* Parent 1 Name, Address, Email & Phone Number:

Parent 2 Name, Address, Email & Phone Number:

* Total number of people living in your household including adults, infants, and children:

* Please indicate the total annual income range for all members of your household:

	Under $25,000
	$25,000 - $35,000
	$35,000 - $45,000
	$45,000 - $65,000
	Above $65,000

Please describe any special circumstances (loss of job, illness, more than 1 child participating in the program, etc.) in your family that may have contributed to your need for financial assistance:

We have integrated a fundraising component in the MASSA Israel Program and believe all students who participate in the Program should help pay for this program’s experience on some level. With the support of parents, we encourage all students to participate in fundraising activities with all funds raised being equally split up by students who specifically participate in fundraising activities and placed in their Israel accounts.

* Will you be able to participate/support fundraising activities?

	Yes
	Not sure

* If the cost of the Israel portion of the program is $4,000 (not including any contributions from fundraising activities or donations), how much scholarship/fundraising dollars would you need?

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Total: