please attach photo Part I: Applicant Information Eighth Graders Israel Experience May 7-19- 2014 APPLICATION Applicant's name (As appears on passport) Last first middle what do you want to be called? Parents'/guardians' names Mailing address Number & street city zip Second mailing address (if parents do not live together) Number & street city zip Home Telephones Parent's day phone: Mother Father Email will be the primary means of communication both before and during the trip. Please provide all email addresses through which we can reliably contact you and your parent/guardian(s): Parent's email: Mother Father Teen's email: Date of birth Male o Female o 1
Passport Passports: We must have the number of your valid U.S. and, if you have one, Israeli passport. o Passport # Please include a copy of the picture page of the passport. Please make certain that your U.S. passport does not expire until at least SIX MONTHS after the conclusion of the trip! o I will apply for a U.S. passport immediately, and inform you of the name and number as soon as I receive it. IF YOU HAVE AN ISRAELI PASSPORT, YOU MUST BRING IT. o I have a valid Israeli passport #. Please make certain that your Israeli passport does not expire until at least SIX MONTHS after the conclusion of the trip! Please include a copy of the picture page of the passport. Anything else you would like to tell us? 2
MEDICAL HISTORY & INFORMATION (To be completed by participant's parents) Participant's Name 1. Is your child a vegetarian? Yes o No o 2. Are there any foods to which your child is allergic? 3. Are there any restrictions on his/her physical activities? 4. Are there any medications or shots that he/she takes regularly? 5. Is there any medication to which he/she is allergic? 6. Physical problems or limitations do not necessarily disqualify a student from participation in the program. However, we must be aware of all conditions in order to plan adequately for your child's well being on the trip. Are there any physical limitations of which our staff should be aware to insure the safety and comfort of your child in this program? 7. It is our experience that more and more people are availing themselves of the services of psychiatrists, psychologists, and counselors to deal with emotional difficulties. Our policy is not to disqualify youths with emotional problems as long as it is the opinion of the staff that the student can function in a program such as ours. A candid description of past, present and potential emotional difficulties will be kept confidential and will enable our Israel staff to work intelligently and sensitively with your child should any unexpected problem arise. It is vital for the safety and comfort of both your child and your child s companions that you be honest and forthcoming with us about potential emotional problems. a) Has your child ever had psychological or drug/alcohol related problems? If yes, please explain. b) Has your child ever had psychological or drug/alcohol counseling or treatment? If yes, please explain. c) Has your child ever been hospitalized for emotional or drug/alcohol related problems? 3
d) Please give full name, address and phone number of professional(s) who have treated your child. 8. Please use another sheet for additional comments or notification of restrictions. PARENTS ACKNOWLEDGMENT AND AUTHORIZATION This health history is correct so far as I know, and the person herein described has permission to engage in all trip activities, except as noted by me and by the examining physician. I understand that failure to reveal physical or emotional conditions that may affect my child s ability to participate fully in trip activities may result in my child being sent home early at the discretion of the Trip Leader, at my expense and without possibility of reimbursement of trip costs. In the event of an emergency, after an effort has been made to contact the parents, guardian, or those listed in the North American Emergency Contact Form, I hereby give permission to the physician selected by The Israel Experience Educational Tourism Services Ltd. and S.S.D.S representative to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. Participant's Name Parent's Signature PHOTO RELEASE I understand that my child may be included in photographs and video footage that may be filmed during the trip. I authorize the The Israel Experience Educational Tourism Services Ltd. and to use these photos/video to promote its programs and services in print, web, and other promotional contexts. Participant s Parents: All parents/legal guardians must sign. Dated: signed: print: Dated: signed: print: Participant: Dated: signed: print: Participant's name 4
Part II: Statement of Responsibility of Program to Participant Jewish Experience in Israel, through its sponsoring organization agrees to: 1. Provide full-time professional supervision and leadership from the time the group departs school until it returns, in order to insure the safety, well being and enjoyment of program participants. 2. Design all program elements in order to conform to the standards of kashrut and to an appropriate observance of the Sabbath. 3. Establish and enforce those rules and expectations necessary to ensure the safety and well being of program participants. 4. Sponsor pre-trip orientation meetings to prepare participants for the program, and to answer any questions that parents might have. 5. Keep parents advised as to the progress of the group during the course of the trip and to promote regular communication between participants and families. Part III: Applicant's Contract/Rules and Responsibilities The following rules have been established to ensure the health and safety of all participants in Jewish Experience in Israel. The applicant agrees to: 1. Conduct him/herself in a manner that reflects well on S.S.D.S & the Jewish community, both while in Israel and while in transit. 2. Participate in all program activities, including mandatory pre-trip sessions. (In case of accident or illness, the applicant or the parent/guardian will notify a staff person immediately.) 3. Property used by the program is not to be abused or defaced in any way. Damage must be paid for by the individual responsible. 4. Conduct him/herself in a manner that does not in any way - whether physically, verbally, emotionally, or otherwise - violate the privacy or well being of another individual. 5. Possession or use of alcoholic beverages or illegal drugs by program participants is absolutely forbidden and will result in immediate suspension and will be grounds for being sent home. 6. The Israel Experience Educational Tourism Services Ltd., in consultation with S.S.D.S will have the sole authority to decide whether the participant, as a result of inappropriate behavior, should be returned to the U.S. ahead of time. I have read and understood these rules and agree to uphold them. I further understand that failure to comply with these rules may result in my being sent home early from the program at my parents expense. Applicant s Signature Date Parent/Guardian's Statement: 1. I have read and discussed these rules and expectations with my child and understand that the Program Director retains the right to arrange for early return home should he/she engage in behavior which is grossly inappropriate and which jeopardizes the health or well-being of program participants or him/herself. I further understand that early separation from the program may result in special airfare charges, as a result of deviation from the group schedule and fares, and agree to accept responsibility for any such special charges. These charges will also apply should my child be returned home early for medical reasons that were not disclosed to us prior to the trip. Signature of Parent/ Guardian Date 5
RELEASE AND WAIVER OF LIABILITY and are the parents of (Mother) (Father) (the teen. ) We understand that this Release and Waiver of Liability is an important document related to the teen s participation in Jewish Experience S.S.D.S (the trip ). We are aware that by signing this document, we are releasing potential claims against the trip s sponsors and others involved either directly or indirectly from liability that may arise as a result of accident or unforeseen events during the trip. We acknowledge that trip activities, including but not limited to hiking, rafting, snorkeling, swimming, camping, bus, jeep and air travel, may be subject to certain hazards, both natural and man made; and further that the teen is voluntarily participating in the trip and these activities with our knowledge, appreciation, and understanding of the dangers and risks involved. We hereby agree to accept any and all risks of the teen participating in the trip. We understand the value of a trip to Israel and further understand that the trip sponsors cannot bear or accept liability for the potential hazards that could, if such were to occur, subject trip sponsors to potential claims. We therefore agree that we, our heirs, next of kin, guardians, successors and assigns, and any other representative of ours will not sue, claim against, attach the property of or prosecute any of The Israel Experience Educational Tourism Services Ltd., and S.S.D.S its directors, officers, agents and employees, and all affiliated entities for loss of property, injury, harm, accident, illness, loss of limb or life, or other personal injury, incapacity, medical cost, expense, damage, claim, liability, howsoever caused, and regardless of whether caused directly or indirectly, by their acts or any other acts, arising out of or in connection with the teen s participation in the trip or activities associated with the trip. Participant: Dated: Signed: print: Participant s Parents: All parents/legal guardians must sign. Dated: Signed: print: Dated: Signed: print: Dated: Signed: print: Dated: Signed: print: 6
EMERGENCY INFORMATION Participant's name Shalom! If you can be contacted at your regular home and work numbers during the entire trip, there is no need for you to fill in Part 1 of this page. However, if you will be away from your regular numbers please give us details of how you can be contacted. 1. On the following dates we will not be at home or at work and can be contacted, in the case of emergency, at: From / /10 to / /10 Tel: ( ) From / /10 to / /10 Tel: ( ) From / /10 to / /10 Tel: ( ) From / /10 to / /10 Tel: ( ) In the event that we, the parents/guardians, cannot be contacted, you may obtain emergency permission regarding our son or daughter from: In Israel (if available) In USA Name Relationship Address Home Phone Business Phone Mobile Phone 7
MEDICAL EXAMINATION BY PHYSICIAN Participant's Name To be completed by a licensed physician This examination MUST be performed within twelve (12) months of departure for Israel. Examination for some other purpose within this period is acceptable. CODE: ü Satisfactory; X Not satisfactory; 0 Not examined (If not satisfactory, please explain). Height Ears Hernia Weight Nose Extremities B.P. Throat Posture (spine) Hgb. Test Teeth Skin Urinalysis Heart Allergies: Please specify Eyes Lungs Glasses Abdomen General Appraisal: (For females) Has this person menstruated? Yes o No o Is her menstrual history normal? Yes o No o Special considerations? Recommendations and restrictions while in Israel: Dietary Restrictions Swimming, diving Exposure to sun and extreme heat Strenuous activity (mountain climbing, hiking, etc.) Other Is there any history of emotional disturbance in applicant? Yes o No o Has he/she shown any of the following: a. Difficulties in relationships with parents, authority figures, persons of his/her own age? Yes o No o b. Behavior disorders Yes o No o c. Emotional symptoms such as mood swings, depression, sleep disorders, unusual degree of anxiety, fear or guilt? Yes o No o Please explain 8
d. Has the applicant been to a psychiatrist within the last 4 years? Yes o No o If yes, permission is requested for a confidential report from the psychiatrist(s) to be sent to our office. e. Is there any congenital malformation now existing that may require special treatment or consideration? Yes o No o If yes, please explain. f. To your knowledge, is there any history of medical, emotional, or drug/alcohol-related problem? Yes o No o If yes, please explain. I have examined the person herein described and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in the program's activities except as noted above. Examining Physician (print) Examining Physician (sign) Address Date (print) MUST BE DATED! State, Zip Code Area Code and Phone Number **NOTE: All medication must be indicated on the attached medication form. 9
Solomon Schechter Day School 8 th Grade Israel Trip 2014 MEDICATION FORM This medication form MUST be completed by a parent and SIGNED BY YOUR PHYSICIAN if your child requires any medication. YOU MUST SEND ALL MEDICATION* one week prior to departure If your child requires ANY medication INCLUDING TYLENOL, INHALERS, EPIPENS, ETC. you and your physician must complete and sign this medication permission slip. *Medicine must be sent in ORIGINAL PHARMACY CONTAINER with the PATIENT S NAME, PHYSICIAN S NAME, NAME OF MEDICATION, DOSAGE AND TIME IT IS TO BE TAKEN. The above rules apply to all medications including Tylenol, inhalers, epipens, etc. STUDENT S NAME (please print) Medication #1 Dosage Time Frequency # of Days Condition for which medication has been prescribed Possible side effects Special instructions_ Medication #2 Dosage Time Frequency # of Days Condition for which medication has been prescribed Possible side effects Special instructions_ Medication #3 Dosage Time Frequency # of Days Condition for which medication has been prescribed Possible side effects Special instructions_ Physician s name and phone (please print) Parent name and phone (please print) PARENT S SIGNATURE DATE PHYSICIAN S SIGNATURE DATE