THE LA Seminary application Name * First Name Last Name Email * Phone * (###) ### #### Birthdate * MM DD YYYY Current Address Address 1 Address 2 City State/Province Zip/Postal Code Country Father born Jewish Yes No Mother born Jewish Yes No Who referred you to the LA Sem? Please include name, number and/or email Do you describe yourself as: Orthodox Conservative Reform/ Reconstructionist Other Current Employment Company Name Company Contact Info. If not currently employed, please explain Other sources of income: Who will be financially responsible for payments? If other than applicant, please explain: * Emergency Contact First Name Last Name Phone (###) ### #### Relationship Medical Information Please answer the following questions. Your information will be kept confidential: Have you ever had surgery? Are there any other psychological or physical health concerns the L.A. Seminary should be made aware of? If yes, please explain (Your information is confidential): Do you have health insurance? Yes No About Me Please tell us a little about yourself: * Why do you want to join the LA Sem? * Thank you for applying to the LA Sem! We will contact you shortly to set up a time to meet.
