Kol Yaakov Jewish Identity & Intermarriage Survey 2009-2010 First Name: Date: Name of College/University: Birthdate: E-mail (Note: will not be distributed): Gender: What is your Jewish affiliation? Reform  Conservative  Orthodox  Unaffiliated  Other  Check any of the below which you participate in at least once monthly: Prayer in a synagogue Shabbat dinner Wear tefillin Light Shabbat candles Deliberately eat kosher food Enter a sukkah on Sukkot holiday [annually] Attend a Passover seder [annually] Family’s synagogue affiliation: Reform  Conservative  Orthodox  Unaffiliated  Other  Is your mother Jewish? Yes No If so: by birth  or conversion Is your father Jewish? Yes No If so: by birth  or conversion Are these your birth parents? Yes No Have you ever dated someone of a different faith in the past? Yes No Would you date such a person now? Yes, I have no problem with it   Maybe; depends on the person   I only date Jewish My attitude about marrying someone of a different faith is: I have no problem with it Depends on the person in question I would not intermarry My feeling about having Jewish children is: I strongly wish to We’ll see what happens My children’s religious affiliation is not critical Has any relative of yours intermarried? Yes No Optional: If yes to above, please specify: Parent Parent in a second marriage Sibling First cousin (e.g. your mother’s sister’s child) Aunt/Uncle Other

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