Last Name: First Name: Sex M F Etternavn: Fornavn: Kjønn: Mann Kvinne
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1 APPLICATION (to be completed by applicant) SØKNDAD (fylles ut av søker) All volunteers are subject to army security clearance Alle søkere vil gjennomgå klarering av det israelske forsvarets sikkerhetsavdeling. Last Name: First Name: Sex M F Etternavn: Fornavn: Kjønn: Mann Kvinne Date of Birth: / / Passport Number: Exp. Date: Fødselsdato: Pass nummer: Utløpsdato: Family Status: Religion: Sivil status: Trosretning: Address: Adresse: Zip (postal code): Postal place: Country: Postnummer: Poststed: Land: Telephone: + Telefonnummer: (med landsnummer, eks ) E-post adresse: Repeat Volunteer? Yes No When were you last at Sar-El? Har du vært i Sar-El før? Ja Nei Når var du siste gang i Sar-El? What countries have you visited in the last 5 years? Hvilke land har du besøkt de siste 5 årene? Occupation: Yrke: Reference (name, , phone) Oppgi referanse (Navn. e-post adresse, telefonnummer) Contact in event of emergency (Name): Kontaktperson i tilfelle nødssituasjon (navn): Telephone: Telefonnr.: e-post: Program Dates: from to TD Hvilket program ønsker du? Fra (dato) Til (dato) Arrival Date (in Israel): Arrival Time: AM PM Ankomstdato til Israel: Ankomst tid: Skriv AM hvis før kl 12 på dagen, skriv PM hvis etter 12 om dagen; ikke skriv f.eks. 13:30 for halv 2, men 01:30 PM.
2 Airline: Flight # Arrival Day: Su M T W T F S Flyselskap: Flight nummer: Ukedag du kommer (sett ring rundt) Departure Date (from Israel) Hvilken dag reiser du fra Israel: Joining Sar-El Program on arrival date? Yes No If no, join date: Kommer du til Israel dagen gruppen starter? Hvis ikke, hvilken dato slutter du deg til gruppen (du kan begynne på de fleste gruppene enten søndag eller mandag) Flights are met on Sun and Mon during normal working hours. (Arrival policies subject to revision) Deltakere hentes på flyplassen søndager og mandager i normal arbeidstid (dette kan endres). The following additional items must accompany your application documents: Følgende må vedlegges søknaden eller ettersendes så snart som mulig: A copy of your passport picture page; a copy of your medical travel insurance policy Kopi av passet ditt (siden med foto) og kopi av dokumentasjon av gyldig reiseforsikring. BRING WITH YOU TO ISRAEL: 3 copies of this application form including the medical form completed by your physician (fast-lege), all four pages! 3 copies of your passport (the page with your photo), and your travel insurance card in effect during your program. TA MED DEG TIL ISRAEL: 3 kopier av denne søknaden inkludert medical form (side 3 og 4) utfylt av din fastlege. 3 kopier av ditt pass (siden med foto og personlige opplysninger, og dokumentasjon på gyldig reiseforsikring. Registration Fee: NOK VAT (tax) NOK 125, all together NOK 625. For applications from Sweden and Denmark the fee is NOK 500 without tax. To be paid to Sar-El Norway's account SWIFT: DABANO22, IBAN: NO Send application to: Sar-El, v/advokat Torger Dahl, Boks 6644 St. Olavs plass, 0129 Oslo, Norway Søknadsgebyr: Kr mva kr. 125, til sammen kr For søknader fra Sverige og Danmark er gebyret NOK 500 (uten mva). Gebyret betales til Sar-El Norges konto SWIFT: DABANO22, IBAN: NO Sønaden sendes til: Sar-El, v/advokat Torger Dahl, Boks 6644 St. Olavs plass, 0129 Oslo, Norge.
3 Waiver and Release/Terms and Conditions Sar-El Volunteers for Israel, hereinafter referred to as "Sar-El", reserves the right to accept or not to accept any person as a member of the program. Sar-El reserves the right to cancel at any time, and to reject any applicant for any reason(s) it deems appropriate. Participants may be immediately dismissed from the program in Israel for proselytizing, use of alcohol or drugs, or other behavior deemed to be dangerous to persons, property, or security. Proselytizing includes discussing your religion with someone who doesn t share your same beliefs in a manner which is intended to be persuasive or which is offensive. This also includes distributing any religious literature. Dismissal from the program will result in immediate removal from the IDF Base (or other program location), and the participant will be solely responsible for expenses incurred thereafter, including but not limited to lodging, transportation, and meals. In addition, program fees paid will not be refunded. I hereby agree to participate in the Sar-El (hereafter, "the Program") upon the express undertakings and acceptances which follow. Wherever the name "Sar-El" is used in this document, it shall be taken to mean Sar-El and any co-sponsors of the Program in whole or in part, and their agents, servants and employees. DECLARATION OF HEALTH I have been advised that the Program may call at times for vigorous exertion and physical effort and under spartan living conditions. I declare that I am in good physical condition and mental health, capable of participating in the Program and that, as may have been reasonably advisable, I have obtained the confirmation of my physician for these purposes. Should it become necessary, this document shall constitute a release of my medical examination records to the appropriate medical personnel in Israel. INSURANCE Prior to my entering the Program, I agree to purchase at my expense accident and health insurance covering medical and hospitalization expenses while in Israel as required by the Program. I understand and agree that I am responsible for any medical bills (including doctors visits, hospitalization, accidents) incurred while I am in the Sar-El Program. I will pay the cost of the treatment and will settle expenses with my insurance company when I return home unless the insurance company agrees to pay the bills directly. (I will have a credit card or sufficient cash to do this). ASSUMPTION OF RISK AND WAIVER OF LIABILITY Having been informed of risks inherent in the Program, I declare that I assume all risks involved in my participation in the Program and waive all claims of responsibility in Sar-El for any losses or damage except as may be caused by its gross negligence or willful misconduct. I expressly accept that Sar-El shall not be deemed responsible for transportation, accommodations, tour programs or other services while I am off the base to which I am assigned unless such off-base event is required by the Program. I agree to hold Sar-El harmless from any and all claims which may be brought against Sar-El on account of misconduct on my part. In participating in the Sar-El Volunteers for Israel, I verify that I have read and accept these terms and conditions, and agree that they shall be binding on me. I also affirm that I have no intention of serving in, joining, or swearing allegiance to the Israel Defense Forces unless this is disclosed in advance. I have no criminal or police record except the following: Signature Date
4 MEDICAL FORM PART 1 of 2 (to be completed by licensed physician) TO THE EXAMINING PHYSICIAN: Please take this application seriously. Ours is a rigorous three-week work program which involves spartan living conditions with no central heat or air conditioning, possibly working in the hot sun, repetitive lifting/twisting/bending, and long hours on one s feet. Your medical evaluation of the applicant s physical condition and stable positive mental outlook is essential to us in determining whether or not to accept the applicant into our program. This information is also vital to enable medical professionals in Israel to appropriately address medical emergencies that this individual may face during the volunteer program. YOU WILL BE DOING A GREAT DISSERVICE TO YOUR PATIENT IF YOU APPROVE SOMEONE WHO HAS MEDICAL OR PSYCHOLOGICAL PROBLEMS THAT MAY CAUSE HARM TO THIS INDIVIDUAL OR OTHERS BY UNDERTAKING THIS WORK EFFORT. Patient Last Name First name Age Sar-El Volunteers for Israel Program target date How long has the applicant been a patient of your practice? MEDICAL HISTORY Allergies: Medications: Surgeries: History of severe injuries: Heart disease Angina Rheumatic fever Hypertension Congestive failure Diabetes Emphysema Asthma COPD Ulcers/GI bleed Diverticulitis Kidney stone Osteoporosis Arthritis Migraine Seizures Cancer Hepatitis
5 SAR-EL APPLICATION PACKAGE MEDICAL FORM PART 2 of 2 PHYSICAL EXAMINATION (note any deviations from normal): Height: Heart: Mouth/Teeth: Weight: Head: Pulse: Abdomen: Lungs: Throat/Thyroid: GU: Eyes: Skin: Extremities: Hearing: Neuro: Other: Eyes: B/P: Can applicant do manual labor? Lift 20 pounds? Bend without pain? Any history of back injury/problems? Will change in diet cause concern for health problems? (For example, Israeli food is generally higher in salt content. PSYCHOLOGICAL PROFILE Conditions imposed by a foreign work program include lengthy absence from family and home, group living situation, new social contacts, and adjustment to cultural differences. Please evaluate psychological and emotional stability: Is the applicant a flexible and agreeable person? Is the applicant capable of working with others? Any history of mental illness, significant depression, bipolar disorder? Any history of being treated by a psychiatrist/psychologist? Use of tranquilizers, anti-psychotics, illicit drugs? PLEASE DO NOT APPROVE ANYONE WHO IS NOT CAPABLE OF WALKING LONG DISTANCES IN HOT, HUMID WEATHER AND WORKING A FULL DAY STANDING I have examined the above named applicant and Do Do not consider him/her physically and emotionally qualified to participate in a rigorous Sar-El Volunteers for Israel work program. Physician s Signature Date PLEASE PRINT Physician s Name (print) Address City St Zip Telephone: ( ) Fax # ( ) Page 5 of 5 L:\Torger\Mine dokumenter\torgers dokumenter\sar-el\skjemaer\sar-el Application form norsk.doc Last Revised: 11/6/2012
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