Name: Maiden name:
Current address: Occupation: D.O.B.:
Home Phone:
Work Phone:
Fax : email:
Marital Status: Select one Single Married Other Children? Select one Yes No How many? Select one 1 2 3 4 5 6 7 8 9 10
Were you a Chanich in Habonim Dror? Select one Yes No What year(s)?
What Shichva? Select one Amelim Sayarim Tzofim Chotrim Bonim What Machaneh? Select one Gilboa Miriam Naaleh Moshava Gesher Galil Other...
Were you a Madrich in Habonim Dror? Select one Yes No What year(s)?
What Tafkid? Select one Madrich Merakez Rosh Machaneh Rosh Ken Techni Rosh Mirbach Cook Nurse / Medic Driver Matzil Other... What Machaneh? Select one Gilboa Miriam Naaleh Moshava Gesher Galil Other...
Did you go on Workshop / Machon? Select one Yes No What year? What number? What Kibbutz?
Which of the following items could be attributed to (in full or in part) to your involvement in Habonim Dror? Select one Chevreh Spouse Career Knowledge of Israel Jewish awareness Parental involvement Education more...

Feel free to add whatever information you want below.

Do you have items from the movement you're willing to donate to Habonim Dror for the Shoshana archive? Select one Yes No