Habonim Dror Event Application

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Habonim Dror

Guidance Completing this Application

The term ‘Applicant’ refers to the person applying to take part on a Habonim Dror programme.

The term ‘Participant’ refers to the person after they have been accepted onto the Habonim Dror programme.

The terms ‘Applicant’ and ‘Participant’ are used interchangeably in this application form. Both refer to the individual applying to take part in the Habonim Dror programme irrespective of whether the individual will be a chanichol (Applicant/Participant) or madrichol (Leader).

Questions on this form refer to the Applicant applying for a Habonim Dror programme. 
Terms and Conditions, and Contractual Age of Majority Declaration

If the Participant is under 18 years of age, it is the responsibility of the Parent/Guardian to sign this form on their behalf and on behalf of themselves.

If the Applicant is 18 years or older, they must sign this form on their own behalf.

The Habonim Dror Information Booklet contains the terms and conditions (including the Code of Conduct and other relevant documents) that form the contractual basis for applying to its programmes. A copy can be found by clicking this link. You will not be able to submit this Form until you have confirmed that you have read the Booklet. Please download it for your records.
By ticking ‘No’ you have confirmed that you are the Parent/Guardian.


Declaration Statement
Hidden fields for Admins only





Applicant Details





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. 




School & Synagogue
This additional information is for research and programme management purposes.                   




The Applicant's preferred Stream of Judaism


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 below.

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

We take equality and inclusion very seriously and do our utmost to make reasonable and proportionate adaptation to accommodate all manner of health and welfare issues. Full disclosure of the Applicant’s needs well in advance allows us to try and cater for their needs while on the Programme. If we are unaware of issues beforehand, we may be unable to provide the required level of support during the Programme resulting in them having to leave the Programme for their safety, and at your expense.
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



Coronavirus (COVID-19)
Yes No

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.
Insurance
Yes No
Insurance Cover for pre-existing conditions is generally not included in the Programme’s medical insurance. It is your responsibility to make suitable and appropriate arrangements. 

Please provide details of any medical insurance you have taken out for any pre-existing medical condition (if applicable), including how to activate cover if necessary - you will be required to activate it.
 
Contact Habonim Dror for clarification of insurance cover for the Programme. 

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
To process your Application, we require payment of the Deposit indicated below. An invoice for the deposit will be sent separately. (In the event the Programme is oversubscribed and/or your Application is not accepted, refunds will be processed in accordance with the terms contained in the Habonim Dror Information Booklet.)

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 – Harrison Engler, on 020 8209 2111 or  harrison@habodror.org.uk

If your Financial Assistance application is unsuccessful and you are unable to proceed, the deposit will be refunded in full.
Payment Information








Application Submission Declaration

Please ensure you have read the Habonim Dror Information Booklet (containing the Terms and Conditions, Declarations and Consents, Code of Conduct, Medical Policy, and Data Privacy Policy). This document can be found by clicking on this link

Please indicate your agreement to the following statement: