Siraj Center for Holy Land Studies
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Application Form

  Name:
  Last: Middle:  
  First:    
 
Home Address :		      
  Street: City:
  State: Zip Code:
  Country:    
  Citizenship:    
  Home phone: Work Phone:
  Cell Phone:    
  E-mail:    
  Gender: Male Female  
  Place of Birth      
  City:    
  Country:    
  Level of education:    
  Do you still studying? Yes No    
  Name of the University:    
  What is your Major?    
  Address:    
  State: Zip Code:
 
Passport Details: 		     
  Issuing Country: Issue Date:
  Passport No. : Expire Date:
         
 
Medical condition:		      
  Do you have any medical Problems? Yes No    
  If yes explain:      
   
  Are you on medication? Yes No    
  What is the name of your medicine?    
       
  Do you have medical insurance? Yes No    
  Company Name: Insurance No. :
  Date of Issue: Expiration Date:
 
Emergency Contacts: 		     
  Name:    
  Day phone no. : Night phone No. :
  Address:    
 
Voluntary work:		      
 

Do you like to make Voluntary Work? Yes No

 
  How many Hours can you make Voluntary work a day:
       
  Number of hours you prefer to make Voluntary work per week:  
       
  Your Main Skills:    
   
  Any special needs?    
 
Payment:		      
  Registration Fees: $180 (non refundable)    
  Duration:      
  One Month
    June 15th - July 15th
    July 16th - August 17th
Two Months		    
 
Accommodation:		      
  By Families
In Guest House
No Accommodation needed		    
 
Courses:		      
  First Month
     Arabic
    History
    Theology
    
  Second Month
     Arabic
    History
    
  Field Trips?    
 


   
Copyrights © Siraj Center for Holy Land Studies, 2006