__________________________________________________________ ________________

APPLICATION
Applicant's Name _________________ _________________ __________________ (please print) ____________________________________________________________________ City ___________________________ State _________________ Country ________________________ Mailing Address (if different than above) ___________________________________________________ ____________________________________________________________________________________ Telephone: : __________________ _______________________ _______________________ Personal Cell Phone: __________________ _______________________ _______________________ Personal E-mail address _________________________________ ________________________________ Date of Birth: month/day/year __________ Place of Birth: ___________ Citizenship: __________ Social Security Number: ______________ Passport Number: ____________________________ Country Issuing Passport: _________________ Current School/Program ___________________________________________________________
FATHER INFO:
_________________ ________________ _____________ ________________ ________________ Last Name ______________________________ ______________________ _______________________
MOTHER INFO:
________________ ____________________ _________________ _______________________ _______________ ______________________________ _____________________ ________________________ Are parents: married, divorced, widowed or separated? _____________ If you live with a guardian, please write his/her name and relationship to you: _______________________________________________________________________________

APPLICATION
continued

Applicant's name _________________________________________________________
(please

SIBLINGS:
Yeshiva attended in Israel (If Applicable)
EDUCATION:


Elementary Schools _____________ _______________ __________________
Secondary Schools _____________ _______________ __________________
Jewish Schools (if not included above)
__________________________________________________________________________

HEBREW SKILLS:

Please rate yourself (Circle or enter a number)
(1=none, 5=fluent)
Read with vowels: __ Read w/o vowels: __ Understand: __
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 What Torah Subjects have you studied? (Give Details) ________________________________________________________________________________________ ________________________________________________________________________________________
EXTRACURRICULAR ACTIVITIES:

Describe your extracurricular activities in and out of school: List programs and organizations you have been
involved with (use additional paper if necessary) ________________________________________________________________________________________ ________________________________________________________________________________________
APPLICATION
continued

Applicant's name ____________________ _____________________
(please print)
What did you do the last three summers? (specify dates) ________________________________________________________________________________________ ________________________________________________________________________________________ Previous visits to Israel (specify dates and/or programs) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ PLEASE LIST THE PEOPLE WHO WILL BE WRITING LETTERS OF RECOMMENDATION FOR YOU: Name ________________________ Position __________________ Phone __________________________ Name ________________________ Position __________________ Phone __________________________ FAMILY OR CLOSE FRIENDS IN ISRAEL (IF ANY): Name _______________________ Address ____________________________________________________ Telephone ___________________ Relationship _________________________________________________ Name _______________________ Address ___________________________________________________ Telephone ___________________ Relationship _________________________________________________ I certify that, to the best of my knowledge, all the above information is true.
Signature of Applicant ________________________ Date _______________________
Signature of Parent/Guardian __________________ Date _______________________
PERSONAL HEALTH HISTORY

Applicant's name _________________________________________________________
(please
1. Height: ____________________________ Weight: ___________________________ 2. Have you or any members of your family suffered from: □ epilepsy □ emotional disturbances □ heart disease □ diabetes □ digestive tract diseases □ other diseases Details: _________________________________________________________________________________ Please check appropriate answer below. If yes, give details Use separate sheet, if necessary.
3. Please list any hospitalizations and diagnosis? Details and Dates: _________________________________________________________________________ ________________________________________________________________________________________ 4. Have you ever received psychological counseling? □ NO □ YES Details and Dates: _________________________________________________________________________ ________________________________________________________________________________________ 5. Are you currently taking any medication? Details and Dates: _________________________________________________________________________ ________________________________________________________________________________________ If yes, indicate which medications: ____________________________________________________________ 7. List any other allergies: ___________________________________________________________________ 8. Do you have any physical limitations? Details:__________________________________________________________________________________ ________________________________________________________________________________________ Contact in Israel to notify in case of an emergency: 1) __________________________________________________________________________________ Number _____________________ Cell _________________________ Relationship ______________ 2) __________________________________________________________________________________ Number _____________________ Cell _________________________ Relationship ______________ This information will be kept strictly confidential PERSONAL HEALTH HISTORY
Applicant's name _________________________________________________________ (please Has your child ever had: (please circle) Perforated eardrum or "tubes" in ears? For Girls Only:
Do you miss school because of your period? PERSONAL HEALTH HISTORY
Applicant's name ___________________ _________________ (please PLEASE PROVIDE AS MUCH DETAILED INFORMATION AS POSSIBLE THIS WILL MAXIMIZE OUR ABILITY TO WORK EFFECTIVELY WITH YOUR CHILD 1. Does your child have any specific medical problems? Please specify. Include allergies to insect bites. ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________________________________________ 2. Does your child have any special eating habits or allergies? Please specify. ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________________________________________ 3. Does your child have any sleeping habits we should know about? ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________________________________________ 4. Does your child have any unusual fears or anxiety? Please specify. If so, how are they handled at home and at work or school? ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________________________________________ 5. Are there any behavioral challenges (i.e temper) we should aware of? How do you deal with them? ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________________________________________ 6. Please note other information we should aware of regarding your child. Remember, information that seems insignificant to you may be very important when working with your child ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ EMERGENCY CONTACT FORM
Applicant's name _______________________________________ Birth Date _________________________ Applicant's Home Address __________________________________________________________________ City ____________________________________________ State ______________ Zip _________________ Phone ( ___ ) ________________________________ In case of an emergency, please contact: Name ___________________________________ Relationship to participant ________________________ Phone ___________________________________ Beeper/Cell ___________________________________ Name ___________________________________ Relationship to participant ________________________ Phone ___________________________________ Beeper/Cell ___________________________________ Name ___________________________________ Relationship to participant ________________________ Phone ___________________________________ Beeper/Cell ___________________________________ Physician to contact in case of an emergency: Name ___________________________________ Relationship to participant ________________________ Phone ___________________________________ Beeper/Cell ___________________________________ Address _______________________________________________________________________________ City _________________________ State ______________________ Zip __________________________ Name of Cardholder __________________________________ Relationship to Participant _____________ Insurance Company _____________________________________________________________________ ID # __________________________________________________________________________________ Group # _______________________________________________________________________________ Coverage includes: □ Prescription Drugs □ out-of-Country Please be sure to include a copy of your child's insurance card with this application Applicant's name ___________________ ________________________ Please write a short essay or provide a video presentation on the topic below. WHAT I HOPE TO GAIN FROM MY YEAR AT DARKAYNU.
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Please remember to include the application fee and two photographs. Please insure that your application and two letters of recommendation arrive prior to the deadline. (This information will be kept strictly confidential) Name of Student: _____________________________________________________________ Father's Name: ________________________ Mother's Name: _________________________ Parents are married ____ divorced ______ separated ______ widowed __________ Address: ____________________________________________________________________ Phone no,: ________________________ Date of Birth: _______________________________ Passport no. : _____________________ Place of Birth: _______________________________ PERSON IN ISRAEL TO NOTIFY IN CASE OF EMERGENCY: Name: ___________________________ Relationship to Student: _______________________ Address: _________________________ Phone: _____________________________________ 1. Height: _________________ Weight: _______________________ 2. Have you or any member of your family suffered from: tuberculosis, epilepsy, emotional disturbances, heart diseases, asthma, diabetes, digestive tract diseases, other diseases. Please check appropriate answer below. If yes, give details, Use separate sheet if necessary. ____________________________________________________________________________________ ____________________________________________________________________________________ 3. Please list any hospitalizations and diagnosis: (__) NO (__) YES, Details and dates: ____________________________________________________________________________________ 4. Have you ever received psychological counseling (__) NO (__) YES, Details: ____________________________________________________________________________________ 5. Are you allergic to any medications: (__) NO (__) YES If yes, indicate which medications: ________________________________________________________ 6. List any other allergies: _______________________________________________________________ MEDICAL EXAMINATION TO BE COMPLETED BY PHYSICIAN Student : ________________________________________________________________________ 1. Vision: _____________________________ Hearing: ____________________________ ______________________________________________________________________________ 3. a) Is the student currently receiving any medications? If so, please attach statement of such b) List any medication that the student has taken regularly at any point over the last three years ______________________________________________________________________________ ______________________________________________________________________________ 4. Has the student manifested any signs of an eating/dietary disorder? ______________________________________________________________ 5. Does the student have any physical limitations: (__) NO (__) YES 6. Date of last tetanus immunization : _________________________________________________ I have examined the above named student and DO consider him/her physically and emotionally able to participate in your program in Israel Name of Physician (please print): ________________________________________________ Address: ____________________________________________________________________ Date: ________________________ Signature: __________________________ - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - To the best of my knowledge all the above information is both accurate and complete Student Signature __________________________________________________________________ Prescription / Non prescription Medications

If your child is not on any prescription medications please go straight to the next page- Part B.

A. Prescription Medication

Please fill out one of these forms for EACH medication. You may use the back of the form if more room is
needed.
Please provide us with as much information as possible pertaining to your child’s medications as it can be a
direct effect on the success of your child in the program.
1 a. What is the name and dosage of the medication you child is currently taking?
_____________________________________________________________________
b. How often? What time of day does your child take this medication_____________
c. Does it say the same thing on the bottle? If no, please explain: YES ___ NO ___
_____________________________________________________________________
d. What is the medication for (what is it supposed to do)? _____________________
_____________________________________________________________________
e. Who prescribed the medication? _______________________________________
f. How long has your child been on the medication for? _______________________
g. Does the medication interact with other medications or something else? _______
_____________________________________________________________________
h. Does the medication have any side effects that your child experiences?
_____________________________________________________________________
_____________________________________________________________________
2.a. How does your child take the medication? ____________________________
b. Is it taken independently? Or is a reminder needed?________________________
c. Has the medication ever purposely not been taken__________________________
3. What is the procedure if a dose is missed? ________________________________
_____________________________________________________________________
_____________________________________________________________________
4. What is your plan for filling the medication during your child’s year in Israel?
(Are you sending replacement, are we filling the prescription- does it have refills on the
bottle or are you sending a prescription?) ___________________________________
_____________________________________________________________________
_____________________________________________________________________

B. Non- prescription medications

The better prepared we are even for the ‘little’ things, the more we can be of assistance to your child throughout
her year and help her gain the utmost from all of her experiences.
1. Does your child get sick often?
Headaches, stomach aches, menstrual cramps, colds, coughs, or other…
______________________________________________________________________________
2. What do you suggest your child should do when he/she is not feeling well? _______________
______________________________________________________________________________
3. What medications does your child take for the above listed ailments? ____________________
______________________________________________________________________________
4. Do you give your child aspirin, Tylenol, Advil? Which seems to have the best effect?
______________________________________________________________________________
5. Can your child swallow pills, or if not how does he/she take medication? _________________
______________________________________________________________________________
For Girls Only:
6. What happens when your daughter has her period? Does she need medication?
Mood? PMS ? Cleanliness? Etc. ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. Other information you think we should know:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Source: http://www.midreshet-lindenbaum.org.il/Data/UploadedFiles/SitePages/121-sFileRedir.pdf