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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
PERSONAL INFORMATION Name _____________________________________ Hebrew Name _____________________________________ Street Address __________________________________ City ______________ State ____ Zip_______________ Date of Birth (Month/Day/Year) ____/____/____ Telephone: Home (_____) _________________________ Work (_____) _________________________ Fax (_____) _________________________ E-Mail Address _______________________________ Gender (Circle One): Male Female Height:_____________ EDUCATION AND OCCUPATION 1) Please circle your level of secular education: High School Attended College Graduated College Graduate School 2) Undergraduate Degree/Major________________________________________ 3) Graduate Degree/Major_____________________________________________ 4) Current Occupation________________________________________________ MARITAL INFORMATION 5) Marital Status (Circle One) Never married Divorced Widowed Other________ 5a) If divorced, please give the name and phone number of the Rabbi who facilitated the Get: 5b) Name of Rabbi_____________________________ Phone Number_______________________ 6) Do you have children (circle one)? Yes No If yes, How many? _________ Age Ranges _____________ Do they live with you (circle one)? Yes No Other(please explain)_______________________________ 7) Women Only: Are you interested in marrying a Kohen? Yes No (If you're not sure as to how to answer this question, please ask your Rabbi or ask the interviewer before making a selection.) JUDAIC BACKGROUND 1) Please describe your level of Judaic education (circle all that apply) 1a) Elementary: Orthodox Conservative Reform Other___________________ Reform Other___________________ Reform Other___________________ Day school or "Sunday" school 1b) High School: Orthodox Conservative Day school or "Sunday" school 1c) College: Orthodox Conservative Day school or "Sunday" school 1d) Other (Yeshiva, courses or shiurim at shuls, schools, etc.) ____________________________________________________ 2) Are you: Ashkenazi Sephardi Other ________________________ 3) Are you: Observant From Birth 4) Are you: Chassidish Ba'al Tshuva Modern Orthodox Convert Yeshivish Conservative Reform Other__________________ 5) If you're a Ba'al Tshuva, how long have you been completely observant (Shabbos, Kashrus, etc.)? _______________ 5a) How long has it been since you've started this process? _______________________________________________ 5b) Are you comfortable with level of observance currently changing (please explain) _______________________________________________________________ _______________________________________________________________ 6) Please describe your religious commitment and present level of observance. ________________________________________________________________ ________________________________________________________________ 7) Do you: Watch or Own TV? Yes 8) Do you: Go to Movies? Yes Never Never Sometimes Sometimes 9) Do you participate in mixed swimming? Yes No Sometimes 10) Do you participate in mixed dancing? Yes No Sometimes 11) Do you: Eat in non-kosher restaurants? Yes Never Sometimes 11a) If Yes or Sometimes, please circle all that apply: Fish Dairy Salads Drinks Other__________________ 12) Women Only: Do you wear pants? Yes Never Sometimes 13) Women Only: When you are married, will you cover your hair? _____________________________________________________________ _____________________________________________________________ 14) Men Only: Are you a: Kohen Levi Yisrael 15) Men Only: Are you comfortable with your wife wearing pants? Yes Never Sometimes 16) Men Only: When you are married, what are your plans for learning Torah? ________________________________________________________________ ________________________________________________________________ 17) Current Synagogue Affiliation: ________________________________________________________________ 18) Name and Telephone Number of Rabbi: ________________________________________________________ HOBBIES AND PERSONAL CHARACTERISTICS 1) How do you spend your spare time (please circle all that apply)? Learning Reading Sports Socializing Cultural Events 2) What do you spend most of your spare time doing? ____________________________________________________ 3) Write three words that describe you: a.__________________________ b.__________________________ c.__________________________ TV/Movies 4) Do you smoke? Yes No Are you willing to date a smoker? Yes No 5) Are you willing to travel to meet someone for a date? Yes No 5a) If Yes, how far?__________________________ 6) Are you willing to relocate if you met the right person? Yes 7) Is making Aliyah to Israel a priority for you? Yes No No Maybe Maybe Feel free to provide any additional information about yourself that may be helpful in finding a suitable match; use additional paper if necessary or just at the bottom of the form. TELL US ABOUT THE KIND OF PERSON YOU WOULD WISH TO MEET 1) Age range of the person you would like to meet?__________________________ 2) Physical attributes (height, weight, etc.) ________________________________________________ 3) Educational Background (circle minimum level): High School College Graduate Degree Does not matter 4) Jewish Education Background: Yeshiva 5) Ashkenazi Does not matter Sephardi Other_________________________________ Does not matter Other_______________________________________________ 6) Marital Status (circle all that apply): Divorced Widowed Never Married Does not matter 7) Will you date someone with children? Yes No ________________________ 8) Affiliation (circle all that apply): Chassidish Modern Orthodox Yeshivish Conservative Reform Other_________ 9) Would you like the person you meet to be (circle all that apply): Observant from birth Ba'al Tshuva Convert Does not matter 10) Women Only: Is it important that your husband learn Torah regularly? ____ Please explain: ________________________________________________________________ ________________________________________________________________ 11) Men Only: Is it important that your wife cover her hair? ____ If so, how? ________________________________________________________________ ________________________________________________________________ 12) Use of spare time (circle all that apply)? Learning Reading Sports Socializing Cultural Events TV/Movies 13) Name three of the most important qualities you seek in a mate: a._____________________ b._____________________ c._____________________ 14) Should making Aliyah to Israel be a priority? Yes No Maybe 15) Feel free to provide any additional information about the type of person you wish to meet that may be helpful in finding a suitable match. Use additional paper if necessary or just at the bottom of the form. PHOTO Please include a recent photo of yourself. REFERENCES Please provide name, address, tel. number and relationship of two references, who are not related to you. (Ref. #1 should be a Rabbi who knows you well.) 1) Name_________________________ 2) Name________________________________ Address__________________________ Address______________________________ City__________State____Zip________ City__________State____Zip___________ Phone___________________________ Phone___________________________ Email___________________________ Email___________________________ Relationship_______________________ Relationship_______________________ ** Someone will contact you within several weeks after receipt of this application to arrange an interview ** This agreement is entered into by the undersigned, who hereby makes application to participate in the Matchmaking program sponsored by the Young Israel of Brookline in Massachusetts and agrees to abide by its policies. The Matchmaking Program is a service offered by the Young Israel of Brookline to facilitate introductions between Jewish single adults. The information on each profile is provided solely by each participant, and Young Israel of Brookline assumes no responsibility for, and makes no representation regarding the accuracy or reliability of such information. By making this application, the undersigned (1) represents that the information provided by the undersigned to Young Israel of Brookline for participation in the Matchmaking Program is true and correct, and (2) assumes the full risk of, and responsibility for, ascertaining the accuracy and reliability of any and all information provided by other participants in the Matchmaking Program with whom the undersigned may interact. It is understood that the undersigned consents to having this profile sent to other shadchanim. Young Israel of Brookline makes every effort to keep records confidential, but assumes no responsibility if information is inadvertently given out. Furthermore, the Young Israel of Brookline and its agents reserve the right to accept as a client any candidate for this program. Having given due consideration to the above, the undersigned hereby releases, acquits, discharges, indemnifies, and holds harmless the Young Israel of Brookline, their officers, directors, agents, independent contractors, volunteers and employees from any and all damages, illnesses (including the possible exposure to AIDS and other infectious diseases), injuries, claims, demands and causes of action of whatever nature and character (and all costs of defense and related thereto) which may accrue to be asserted by the undersigned, any other participant in the Matchmaking Program, or any person or entity claiming by, through, or on behalf of the undersigned, or any other participant in the Matchmaking program arising directly or indirectly out of the application or participation by the undersigned. Name (please print):_________________________________ Date:______________ Signature:________________________________________________________________ Please return to: Young Israel of Brookline - Shidduch Committee 62 Green Street, Brookline, MA 02446