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  5. Berit Mila Course
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Exit Survey
 
 
Thank you for your interest in out Berit Mila program.
In order to help us enroll you in our next course, please answer the questions to our short survey.
As we reach the number of students necessary, we will provide you with the dates of the next class.

Thank you very much for your interest in our program. Please start with the survey now by clicking on the Continue button below.
 
 
 
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* State : 
* Zip : 
* Phone : 
* Email Address : 
 
 
 
What is your profession ?
 
MD
 
DO
 
RN / Midwife
 
Other
 
 
 
 
What is your specialty (Select all that apply) If subspecialty, indicate in section for other?
 
Pediatrics
 
OB/GYN
 
Family Practice
 
Urology
 
Surgery
 
Other
 

 
 
 
What congregation do you currently belong?
 
Reform
 
Conservative
 
Reconstructionist
 
Modern Orthodox
 
Other
 
 
 
 
How did you learn of our program ?
 
Web search
 
Heard from a friend
 
Mentioned by my rabbi
 
Received information from mohel at a bris I attended
 
Other
 
 
 
 
Are you aware that our course in presented over a 12 week period online and with your local congregational rabbi's mentorship?
 
Yes
 
No
 
Other
 
 
 
What is your status in the following areas:
Active Pending Courtesy Restricted N/A
Medical license
Malpractice insurance
Synagogue or Temple membership
 
 
 
Are you currently proficient in newborn circumcisions ?
 
Yes
 
No
 
In process of learning
 
Other
 
 
 
 
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