JLIC Sign Up Form

Are you are a prospective student or incoming freshmen? Tell us a little about you and which college you are interested in/attending. This way we can have a JLIC Campus Director or other Jewish Life on Campus Professional connect with you, make sure you are in the know about Jewish life on your campus of choice, and hey, you never know when a Shabbat invite will be coming your way!

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Student Information
Name*
First Last
Gender*
- Male
- Female
Email Address*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Home Phone
Parents Info
Parent #1 Full Name
Parent #1 Email
Parent #1 Phone
Parent #2 Full Name
Parent #2 Email
Parent #2 Phone
High School*
High School Graduation Date*
Did you participate in a gap year program in Israel?*
Please Enter The Yeshiva / Israel Program You Attended
College / University*
Please Enter The College / University You Attended
NCSY Region/Chapter
Expected College Start Date*
What shul do you attend?

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Student Information

Parents Info