de Hirsch Residence Application Form Page 1 of 4 - 92nd Street Y

0 item(s)



de Hirsch Residence Application Form

Please be advised that the completed application is NOT a confirmation. This application is not confirmed and space is not booked for you at the de Hirsch Residence until we notify you.

It should be understood that any false statements of a material fact may result in rejection of this application, and in case of acceptance, may in and of itself be a reason for terminating residence. The de Hirsch Residence is not just a place to live. The Residence Program is designed to serve young adults who wish to live in New York City and who desire to dwell in an atmosphere permeated by culture and international understanding. In this setting they can find friends in a congenial, social, and educational environment. Careful screening and selection of applicants who are deemed suitable for a non-transient dormitory environment is important in accomplishing the special goals of the de Hirsch Residence.

All information given to us on this Application Form will be treated as confidential.

The 92 Street Y and de Hirsch Residence is a Smoke-Free facility. Smoking is prohibited in all areas of the building, including Residence rooms.

The 92nd Street YM-YWHA is an agency of UJA-Federation

Address	Telephone/Email
de Hirsch Residence 92nd Street YM / YWHA 1395 Lexington Avenue New York, NY 10128	In New York: 212.415.5650 In USA and Canada: 800.858.4692 fax: 212.415.5578 email

Page 1 of 4

Required Fields

First Name

M.I.

Sex

MaleFemale

Last Name

Date of Birth

(mm/dd/yyyy)

Telephone

Age

Fax

Place of Birth

Citizenship

For foreign students only, what type of visa do you hold?

Permanent

(Home) Address

Current (Local) Address

City

State

Zip Code

Country

Status

SingleSeparatedMarriedDivorced

Family (Please list parents and siblings)


Please indicate full name	Age	Relationship	Occupation	Educational Background






Are your parents:	Living TogetherSeparatedDivorcedRemarriedDeceased

	Contact Us \| Privacy Statement \| Policies \| Site Map \| Help \| Press Resources

	© 2008 92nd Street Young Men's and Young Women's Hebrew Association All Rights Reserved. Click here for directions

	Web Accessibility and the 92nd Street Y