Habonim Dror Event Application

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Habonim Dror

Contractual Age of Majority Declaration (Age 18)
Questions on this form relate to the Participant applying for Habonim Dror programme. If the Participant is under 18 years of age, it is the responsibility of the Parent/Guardian to sign this form on their behalf. If the Participant is 18 years or older, they must sign this form on their own behalf.

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DD/MM/YYYY

DD/MM/YYYY


Applicant Address Information




Applicant Contact Details




Travel Preferences
At their discretion Habonim Dror may aim to coordinate and provide travel options to the event from locations around the country. Please indicate your preferred travelling arrangements. You will be advised of the details and any additional costs prior to the event. 




Data Protection

By submitting the Online Application Form, the Applicant or Parent/Guardian (if Applicant is under 18) consents to and agrees that the Applicant’s personal data including Medical Data may be used:

§   For the processing of personal data outside the EEA pursuant to the Data Protection Act 2018;

§  In the case of emergency and disclosed to third parties (including emergency services, medical teams and governmental or regulatory bodies in the UK);

§   For dealing with any legal matters which may occur (eg: sharing information with lawyers and insurance companies);

§   For arranging insurance cover in respect of the Programme to the insurance company in the UK;

§   To assess the Applicant's suitability for the Programme and the activities it entails;

§   By The Organisers in relation to medical or welfare support if required;

§   For general administration of the Programme;

§  To conduct anonymised statistical research using elements of the Applicant’s data for the purposes of improving programmes for the future;

§ In assisting the crisis management team that are on standby to deal with any issues that may arise whilst the Participant is participating in the Programme;

§   For any other safeguarding, medical or legal issue that The Organisers deem to be reasonable; 

§   For any other social, discipline or welfare issues that The Organisers deem to be reasonable.

Publicity and Communications
Yes No
Yes No

Parent/Guardian #1 Contact Details





















Please Note: there is an option to add information regarding a third nominated contact, other than a Parent/Guardian.


Parent/Guardian #2 Contact Details












Yes No

Third Nominated Contact (other than Parent/Guardian 1 & 2)


While the Applicant is on the programme, it is important that Habonim Dror should be able to contact a responsible adult at any time, should the Parent/Guardian(s) be unavailable. This person should be contactable by phone/email at any point throughout the programme and should be prepared to take responsibility for the Applicant should they need to return home. Please inform this person of the above and ensure that they are aware of the dates of the programme and that in an emergency they will be contacted during unsociable hours.









Yes No

Emergency Contact Person in Israel


Please give details of someone based in Israel who can be contacted in case of emergency. 
Please inform them that they have been nominated on this form.








Yes No

Friends


If you wish, please name a maximum of three friends with whom the Applicant would like to be roomed with for the programme. We will do our best to accommodate one of your choices, however please note that we make no guarantees. Please note that the names listed are not in priority order. Rooming requests will only be made based on those preferences submitted online.


Please ensure that you write the full names of the friends with whom you are requesting to be roomed with.


If this field is left blank, we will take it that the Applicant has no preferences.





Miscellaneous



Dietary/Allergies (Food and Non-food)


Disclosing full and complete information regarding allergies is extremely important so that Habonim Dror can fully understand the needs of the Applicant.

Habonim Dror are unable to make any guarantees or commitments regarding allergy triggers.

As a reminder, any Applicant that has an EpiPen should bring a minimum of three doses on the Programme. One of these doses will be on the Applicant at all times and the other two will be held by the Madrichimot (Leaders). If an EpiPen is used, lost, damaged or stolen it must be replaced on the Programme at the family's expense as it will not be covered by the medical insurance.

As a reminder, any Applicant that has an EpiPen should bring a minimum of three doses on the Programme.
Yes No
Dietary/ Intolerance requirements
This question concerns dietary requirements. However, we are only able to address these requirements within the limitations of the Programme. Participants are required to take responsibility for monitoring their own dietary intake.


Allergies/ Signs and Symptoms of Allergic Reaction


These questions should be answered where an Applicant has any allergy or intolerance diagnosed by a healthcare provider (including those indicated in the previous question and also including both food and non-food allergies e.g. animals, stings, medications, latex, etc...). If you have been given an allergy management protocol document by a medical practitioner, please provide a copy of this.

If you have an allergy, you must read and agree to the terms of the Allergy Waiver which will appear on the screen.

This online application provides facilities to indicate up to three (3) allergies. Should you need to advise of more, please contact the Habonim Dror offices.
List of Allergies Allergy Level Age of Applicant at original diagnosis Allergic reaction is triggered


Common symptoms - Skin: hives, itching, rash, flushing, swelling (face, arms, hands, legs). Mouth: itching, swelling (lips, tongue, mouth). Abdominal: nausea, cramps, vomiting, diarrhoea. Throat: itching, tightness, difficulty swallowing, hoarseness, cough. Lungs: shortness of breath, repetitive cough, wheezing, tightness of the chest. Heart: chest pain, loss of consciousness.




Please include information regarding medication (name, frequency and dosage) as well as other treatments for the condition. If the Applicant has a diagnosis but has never had a reaction, please indicate this and provide information regarding treatment and medication recommended by a healthcare provider for use in case of an allergic reaction.

N/A Yes No
Yes  No
Yes No
I agree
All Applicants with an allergy must fully complete the Allergy questions on the Online Application Form so that Habonim Dror can fully understand the specific needs of each Applicant prior to the programme which, in the large majority of cases, Habonim Dror is able to cater for. 

As is standard practice, many food products contain warnings that the product may contain nuts, sesame, milk, etc., even if the ingredients do not specifically contain these things. Consequently, Habonim Dror are unable to provide food that it can guarantee was made in an environment free from specific foods..

Different countries across the world have different food cultures.  As such, foods which may be common in the UK may be rarely seen in other countries, and vice versa, foods that may be rarely used in the UK may be very common elsewhere.  As such, foods that Participants may not expect to find as an ingredient in a meal, whether visible or not, could be there.

Therefore, it is essential for you to provide us with very specific information relating to any food allergy (including whether reaction occurs with airborne food particles) to make us aware of the possible risks in addition to signing the waiver below. As a reminder, any Applicant that has an EpiPen should bring a minimum of three doses on the Programme. One of these doses will be kept on the Applicant at all times and the other two will be held by the Madrichimot (Leaders). If an EpiPen is used, lost, damaged or stolen it must be replaced on the Programme at the family's expense as it will not be covered by the medical insurance.

Please note that it is the Applicant’s responsibility to ensure they fully understand what they are consuming before doing so.

Medical Conditions

Applicant's Doctor/General Practitioner



Within the past six months, has the Applicant experienced any of the following:
None Yes



Depending on the severity of the condition(s), you may be required to provide additional information and/or documentation. It is likely that this will need to be written by a Doctor/Specialist/Consultant/or other medical professional as required.  In cases where a medical practitioner is required to provide such documentation, they will need to be provided with a description of the  programme and be asked for details of: the condition, limitations and capabilities of the Applicant's ability to participate in the programme and its sub-parts, frequency of medication and treatment, together with their contact details.

In order to ensure that the Application process is completed as efficiently as possible, we recommend that you alert the Doctor/Specialist/Consultant/or other medical professional as soon as possible that this may be required of them in order for the Applicant to participate in the programme.


More than six months ago, has the Applicant experienced any of the following:
None Yes


Depending on the severity of the condition(s), you may be required to provide additional information and/or documentation. It is likely that this will need to be written by a Doctor/Specialist/Consultant/or other medical professional as required.  In cases where a medical practitioner is required to provide such documentation, they will need to be provided with a description of the  programme and be asked for details of: the condition, limitations and capabilities of the Applicant's ability to participate in the programme and its sub-parts, frequency of medication and treatment, together with their contact details.

In order to ensure that the Application process is completed as efficiently as possible, we recommend that you alert the Doctor/Specialist/Consultant/or other medical professional as soon as possible that this may be required of them in order for the Applicant to participate in the programme.



Habonim Dror is committed to inclusion and as such, we aim to make reasonable adjustments to the Programme to include all Applicants where it is reasonably possible to do so. Disclosing full, clear and accurate information regarding all medical conditions is therefore crucial so that we can fully understand the needs of the Applicant. Failure to fully disclose the information requested above, and/or any further information that may be required, will cause delay and may result in the Applicant being unable to join in the Programme. Habonim Dror will be in contact with you directly should they require more information.

Medication

Yes No

Yes No

Please note: the Applicant is responsible for managing and monitoring the administration of their own medication. The Madrichimot (Leaders) are not medically trained and although there will be a First Aider on the programme, it is not their responsibility to ensure medication is taken.


Further Medical Information

Comments on the Applicant's current state of health (incluing all aspects of health and well-being):

Yes No

Please include start and end date of therapy (or indicate that it is ongoing), frequency of appointments as well as the reason(s) for the Applicant attending. If the Applicant has had more than one course of counselling/psychotherapy/psychological/psychiatric etc. help, please provide dates and causes for each course individually.
If the Applicant has received any form of counselling, psychotherapy, psychological or psychiatric etc. help we may require an accompanying Mental Health Form, which Habonim Dror will provide where necessary, to be completed by a Counsellor/Doctor/Specialist. The form includes a description of the programme and asks for details of the condition, limitations and capabilities on the Applicant's participation in the programme and its sub-parts, frequency of medication and treatment together with the Counsellor/Doctor/Specialist's contact details. (If this occurred within the last three years we will definitely require the medical practitioner's report.)
In order to ensure that the Application process is completed as efficiently as possible, we recommend that you alert the Counsellor/Doctor/Specialist as soon as possible that this may/will be required of them in order for the Applicant to participate in the programme.
Yes No

Please include dates and time-frames of how long it took for the Applicant to recover, medication that was taken, ongoing treatment and whether it will have any impact on the Applicant's ability to fully participate in the the Programme.

Yes No

For each condition please include: Name of Condition, dates the Applicant suffered from this condition (start & end), severity, treatment, medication, likelihood of recurrence on the programme, stability of condition over the past 6 months.

Fears or Phobias
Yes No

Further Medical Information


Self-Harm is defined as "intentional self-poisoning or injury, irrespective of the apparent purpose of the Act" (National Institute for Clinical Excellence, 2014). It includes all forms of behaviour which damage your body in any way either internally or externally, including swallowing any substances which might be harmful to your body (or causing damage to your mental state of health or well-being).
Yes No


Eg: Anything that has occurred in the last ten years that you think would be useful for us to know including emotional stress, illness, divorce or bereavement. If none, enter None.
Yes No

Further Medical Information

Immunisations

Every Parent/Guardian (or Applicant) is responsible for and required to ensure that the Applicant obtains any required and recommended immunisations at the appropriate time prior to departure. We understand that good general practice requires all young people to have had the appropriate immunisations for Polio, MMR and Tetanus and we strongly encourage all Applicants to follow this guidance. Therefore, all Applicants are understood to have had these immunisations. Where this is not the case, the Parent/Guardian (or Applicant) will be held wholly responsible for any illness or infection contracted on the Programme where immunisation prior to the commencement of the Programme may reasonably have been expected to protect against the condition
In relation to Tetanus (as well as other conditions), should the Applicant not have had a booster within the last 10 years prior to the commencement of the programme and they contract an illness or infection as a result, costs, including but not limited to the administration of a Tetanus injection should it be required and any travel including the return home, will not be covered by Habonim Dror. The Parent/Guardian or Applicant (as appropriate) will be responsible for any and all costs incurred for any treatment and travel received as a result of this. We will rely on information supplied on this Medical Form relating to these matters. 
For the avoidance of doubt, should circumstances arise, the Medical Authorities will administer a Tetanus injection as they deem to be appropriate and will do so following medical protocol. If you have any questions regarding the above, please contact Habonim Dror
Yes No Not known



Hepatitis B Vaccination Dates
Some of the activities included in the programming on the Programme requires vaccination against Hepatitis B.
Yes No Not known



Miscellaneous Vaccination and Dates
It is a mandatory requirement of the Ghanaian government to be vaccinated against Yellow Fever to enter the country.  A mandatory requirement of the Programme is to be vaccinated against Hepatitis B.  Furthermore, it is advised by many travel health agencies, that people that visit Ghana should have been vaccinated for Diphtheria, Hepatitis A, Meningitis, Pneumococcal, Polio and Whooping Cough.
Yes No Not known

Yes No Not known

Yes No Not known

Yes No Not known

Yes No Not known

Yes No Not known

Yes No Not known

Payment

Payment Info
In order to process your Application, we require payment of the Deposit indicated below. (In the event the Programme is oversubscribed and/or your Application is not accepted, this Deposit will be refunded in full.)

Financial Assitance

Habonim Dror is committed to financial inclusion. If you are unable to pay the full Deposit at this stage, contact us to discuss; we may be able to offer financial assistance in the form of payment plans and/or bursaries to families needing help.  


Contact our Gizbar (Treasurer) in confidence – Harry Nelson, on 020 8209 2111 or  HarryN@habodror.org.uk

Price and Deposit

Those applying for Financial Assistance can pay a reduced deposit at this stage, minimum £50. If your Financial Assistance application is unsuccessful and you are unable to proceed, the deposit will be refunded in full.
Payment Information








Declarations, Terms and Conditions, and Consents


I declare that I am applying for the Camp/Activity stated on the Application Form on behalf of my Child/Ward and undertake to pay the full fees by the stated deadline (and any travel expenses if the named Child/Ward is not travelling according to arrangements made by Habonim Dror).

I understand that:


1. No Applicant (including Leaders) will be allowed to participate in a Camp/Activity unless Habonim Dror has received (a) a fully completed Agreement and Medical Form (and Parental/Guardian Consent and Agreement where applicable), and (b) full payment, unless alternative arrangements have been made in writing prior to the specified date.
2. Places on each Habonim Dror UK Camp/Activity are limited, and completion of the Agreement and Medical Forms does not guarantee acceptance.
3. The Deposit is non-refundable in all cases where the Applicant cancels or does not attend the Camp/Activity for which their application has been formally accepted. Any further refund or payment due will be subject to the Cancellation Policy for the specific Camp/Activity. Where Habonim Dror decides to cancel the Camp/Activity for whatever reason all monies paid by the Applicant to Habonim Dror for the specific Camp/Activity will be refunded. 
4. The prices, dates and times stated in the Application Form are subject to confirmation. Any changes will be published as soon as they are known. Furthermore, there may be unforeseen delays or changes.
5. Only for very special reasons will a Participant be permitted to arrive late or leave early from any Camp/Activity or be taken away from the Camp/Activity at any time, and then only with prior arrangement and when the Participant is accompanied by an agreed adult as appropriate.
6. Habonim Dror reserves the right to reject an Application based on prior behavioural issues, or to take such issues into account for behaviour management at the Camp/Activity. 
7. The Leaders of the Camp reserve the right to send home any Participant that is considered unsuitable for the Camp/Activity. Should any Participant (including Leaders – throughout this document) be sent home for contravening the rules of the Camp/Activity set down by Habonim Dror or have to return home due to illness or of their own volition, they (and/or their Parents/Guardians) will be liable for all the Travel Costs incurred (plus any related costs involved) and may, at the discretion of the Leaders, they (or nominated Relative or Friend) be required to collect their Child. In such circumstances, NO refund will be given.
8. It is a legal responsibility that everyone on a private Bus/Coach is required to wear a seatbelt. Should the Participant not be wearing one, the Participant (or their Parents/Guardians where appropriate) accept full responsibility for the consequences, including and associated fees, fines and insurance-related matters.
9. It is Habonim Dror’s policy that Participants are not permitted to take mobile phones on Camps/Activities (with the exception of Muchanim and Madatzim where they must only be used at specified times and not during the programme time). If one is brought, it will be withheld for the duration of the camp but Habonim Dror cannot be held responsible for its safe return. These items are not covered on the Insurance policy.
10. By signing/submitting the Application Form (of which this document forms an integral part) the Applicant (or their Parents/Guardians where applicable) accepts that photographs of themselves can be used for Habonim Dror’s marketing activities, which includes online, social and print media. Upon request, specific photographs which have been published online can be removed.
11. Cigarettes, vaping, alcohol, all illegal drugs, all illegal substances, caffeine-based products (and any misuse of legal substances – as determined solely by Habonim Dror) are strictly forbidden, and their use completely prohibited on the Camp/Activity. Involvement with any of the above will likely result at Habonim Dror’s sole discretion those concerned being sent home immediately at the expense of the Participant (or Parent/Guardian if the Participant is under 18 years of age), and no refund being given. The decision
12. No weapons of any kind including pocket knives, or Bullying or any other forms of anti- social behaviour will be tolerated. Nor will leaving the site without permission be tolerated.
13. Any Participant carrying out an action regarded by a Camp Leader as wilful damage will be held liable for this damage. The Participant (and/or Parents/Guardians as applicable), will be held responsible for the full payment of any costs incurred due to this damage, or any subsequent related costs.
14. Habonim Dror reserves the right to search the luggage/belongings of any Participant.
15. Habonim Dror accepts no liability or responsibility for any damage or loss of personal possessions of any of the participants under any circumstances.
16. If the Participant has any special considerations or pre-existing conditions of any kind (physical, mental, dental, optical or other) the Participant will need to take out their own Insurance Cover.
17. We advise that Participants do not bring any valuables with them as there is no insurance cover provided for such items. Valuables, by definition, include items such as cameras, mobile phones, iPods, iPads, laptops, and jewellery.

I declare that I am applying for the Camp/Activity stated on the Application Form on behalf of myself and undertake to pay the full fees by the stated deadline (and any travel expenses if I not travelling according to the arrangements agreed with Habonim Dror).

I understand that:

1. No Applicant (including Leaders) will be allowed to participate in a Camp/Activity unless Habonim Dror has received (a) a fully completed Agreement and Medical Form (and Parental/Guardian Consent and Agreement where applicable), and (b) full payment, unless alternative arrangements have been made in writing prior to the specified date.
2. Places on each Habonim Dror UK Camp/Activity are limited, and completion of the Agreement and Medical Forms does not guarantee acceptance.
3. The Deposit is non-refundable in all cases where the Applicant cancels or does not attend the Camp/Activity for which their application has been formally accepted. Any further refund or payment due will be subject to the Cancellation Policy for the specific Camp/Activity. Where Habonim Dror decides to cancel the Camp/Activity for whatever reason all monies paid by the Applicant to Habonim Dror for the specific Camp/Activity will be refunded. 
4. The prices, dates and times stated in the Application Form are subject to confirmation. Any changes will be published as soon as they are known. Furthermore, there may be unforeseen delays or changes.
5. Only for very special reasons will a Participant be permitted to arrive late or leave early from any Camp/Activity or be taken away from the Camp/Activity at any time, and then only with prior arrangement and when the Participant is accompanied by an agreed adult as appropriate.
6. Habonim Dror reserves the right to reject an Application based on prior behavioural issues, or to take such issues into account for behaviour management at the Camp/Activity. 
7. The Leaders of the Camp reserve the right to send home any Participant that is considered unsuitable for the Camp/Activity. Should any Participant (including Leaders – throughout this document) be sent home for contravening the rules of the Camp/Activity set down by Habonim Dror or have to return home due to illness or of their own volition, they (and/or their Parents/Guardians) will be liable for all the Travel Costs incurred (plus any related costs involved) and may, at the discretion of the Leaders, they (or nominated Relative or Friend) be required to collect their Child. In such circumstances, NO refund will be given.
8. It is a legal responsibility that everyone on a private Bus/Coach is required to wear a seatbelt. Should the Participant not be wearing one, the Participant (or their Parents/Guardians where appropriate) accept full responsibility for the consequences, including and associated fees, fines and insurance-related matters.
9. It is Habonim Dror’s policy that Participants are not permitted to take mobile phones on Camps/Activities (with the exception of Muchanim and Madatzim where they must only be used at specified times and not during the programme time). If one is brought, it will be withheld for the duration of the camp but Habonim Dror cannot be held responsible for its safe return. These items are not covered on the Insurance policy.
10. By signing/submitting the Application Form (of which this document forms an integral part) the Applicant (or their Parents/Guardians where applicable) accepts that photographs of themselves can be used for Habonim Dror’s marketing activities, which includes online, social and print media. Upon request, specific photographs which have been published online can be removed.
11. Cigarettes, vaping, alcohol, all illegal drugs, all illegal substances, caffeine-based products (and any misuse of legal substances – as determined solely by Habonim Dror) are strictly forbidden, and their use completely prohibited on the Camp/Activity. Involvement with any of the above will likely result at Habonim Dror’s sole discretion those concerned being sent home immediately at the expense of the Participant (or Parent/Guardian if the Participant is under 18 years of age), and no refund being given. The decision
12. No weapons of any kind including pocket knives, or Bullying or any other forms of anti- social behaviour will be tolerated. Nor will leaving the site without permission be tolerated.
13. Any Participant carrying out an action regarded by a Camp Leader as wilful damage will be held liable for this damage. The Participant (and/or Parents/Guardians as applicable), will be held responsible for the full payment of any costs incurred due to this damage, or any subsequent related costs.
14. Habonim Dror reserves the right to search the luggage/belongings of any Participant.
15. Habonim Dror accepts no liability or responsibility for any damage or loss of personal possessions of any of the participants under any circumstances.
16. If the Participant has any special considerations or pre-existing conditions of any kind (physical, mental, dental, optical or other) the Participant will need to take out their own Insurance Cover.
17. We advise that Participants do not bring any valuables with them as there is no insurance cover provided for such items. Valuables, by definition, include items such as cameras, mobile phones, iPods, iPads, laptops, and jewellery.

Medical Policy

The Participant certifies that they are fit to participate on the Camp/Activity and that to the best of the Participant’s knowledge the medical information provided for this Camp/Activity is complete and correct in all details (where appropriate this information and confirmation will need to be provided by the Parents/Guardians). 
The Participant (and/or Parents/Guardians as applicable) agrees to the Participant receiving medication as detailed, and in any medical emergency, dental or surgical treatment, including anaesthetics or blood transfusions, as considered necessary by the appropriate medical authority, understanding that Habonim Dror cannot, and will not, be held liable for any incident caused as a result of incomplete or inaccurate medical information being supplied (please note that the Gillick competence and Fraser guidelines will apply). 
It is further understood that Habonim Dror reserves the right to send home any Participant as a result of incomplete, inaccurate medical information being supplied and any medical/emotional/psychological condition that cannot be managed using accepted safe practices whilst on the Camp/Activity.
Prior notice of medication will need to be supplied and agreed in advance.
The Medical Declaration forms an integral component of this agreement.

Cancellation and Refund Policy

1. In the event the Camp/Activity is oversubscribed and/or the Application not formally accepted for whatever reason all monies paid will be refunded. 
2. All requests to Cancel an application or a confirmed place on a Camp/Activity must be in sent in writing to office@habodor.org.uk .
3. If a specific Deposit Payment Deadline is indicated, the Deposit will be refunded for Cancellations received prior to this date less an Administration Fee.
4. Any Deposit paid is non-refundable in all cases where the Applicant cancels or does not attend the Camp/Activity for which their application has been formally accepted. 
5. All payments received are non-refundable in all cases where Cancellation is received less than four (4) weeks before the start of the Camp/Activity. Similarly, if you fail to provide information requested which is material for assessing the Application, Habonim Dror reserves the right to cancel the Application and apply these terms for any payments received.
6. Unless otherwise indicated, refunds will be subject to an Administration Fee of £50.
7. Where Habonim decides to cancel the Camp/Activity for whatever reason all monies paid by the Applicant to Habonim for the specific Camp/Activity will be refunded in full.
8. Where circumstances dictate that Habonim Dror must change the date for the Camp/Activity the Applicant will have the choice of either retaining their confirmed place or requesting a full refund of all monies paid.