Jewish Prisoner Services International

JPSI Pen Pal Program Application

Print this form and mail it to your loved one to complete.

Please tell us about yourself: Date: _________________________

Name: _____________________________ Register number: _______________________________

Current address: ___________________________________________________________________

City: _________________________ State: __________________ Zip: ________________________

Release date: __________________ Years of Jewish education: ____________________________

Current religious affiliation: _________________________________________________________

Hebrew name: _____________________________ Who referred you to JPSI? _______________

Synagogue: ________________________________ Rabbi: ________________________________

Mother’s name: ________________________________________________ Jewish? □ Yes □ No

Mother's Hebrew name: ____________________________________________________________

Father’s name: _________________________________________________ Jewish? □ Yes □ No

Father's Hebrew name: _____________________________________________________________

Tell us about yourself (interests, hobbies, favorite sports, shows, movies, books, etc.):

Please describe the kind of person you would like as a pen pal:

Name of closest friend or relative to contact in case of emergency: _______________________

Address: _________________________________________________________________________

City: _________________________ State: _________________ Zip: ________________________

Phone number: ____________________________________________________________________

By my signature below, I agree to adhere to the guidelines of this organization and treat my pen pal with the honesty and respect s/he deserves. I also understand and agree that romantic fulfillment is not the purpose of this endeavor.

Sign here: _____________________________________________