Habonim Dror Event Application

Programme Name

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.

Is the Participant 18 years of age or older?

YesNo

By ticking ‘No’ you have confirmed that you are the Parent/Guardian.

Declaration Statement

I have read, understand, and accept the conditions in the Habonim Dror Information Booklet

Agreed in my capacity as

HIDDENLLN

Program Price To Hide Payment Page	Program Deposit To Hide Payment Page	AppID
Year	ContactID	ProgID
ProgName	LogoID	ProgType Program Year

Applicant Details

First Name	Middle Name	Last Name
Preferred Name	Birthdate DD/MM/YYYY	Birthdate DD/MM/YYYY
Gender	Gender (Other)

Applicant Address Information

Address	City	Country
Postal Code

Applicant Contact Details

Mobile Telephone	Home Telephone	Email -This is the email address that will be the main point of contact for Habonim Dror for this event and throughout the year.
Email

Have you attended other Habonim residential events in the past?

YesNo

If yes, please select the programme

Applied to previous residential events?

YesNo

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.

Preferred Pickup Point:

Other Pickup Point

Preferred Drop-off Point:

Other Drop-off Point

School & Synagogue

This additional information is for research and programme management purposes.

School Name

For Primary click 'Other' and complete

If selected 'Other'

Synagogue

Other Synagogue

The Applicant's preferred Stream of Judaism

Stream of Judaism

If selected 'Other'

Publicity and Communications

	Yes	No
Would you be interesting in hearing about future programmes, activities by Habonim Dror (outside of 'legitimate interest' communications)?

I’m happy for you to contact me by

EmailTelephoneMailSMS

	Yes	No
I give Habonim Dror permission to use any still and/or moving image including video and audio footage, depicting the Participant, taken on behalf of Habonim Dror on the Programme for promotional and marketing materials, training, education and social media.

Parent/Guardian #1 Contact Details

Title

First Name

Last Name

Marital Status

Relationship to the Applicant

Other

Mobile Telephone	Home Telephone	Work Telephone
Primary Email Address	Primary Email Address -This is the email address that will be the main point of contact for Habonim Dror for this event and throughout the year.

Address	City	Country
Postal Code

Please confirm that you are the legal guardian (with authority to complete this form on your child's behalf)

I am legal guardian

Please confirm that you will be in the UK throughout the programme should Habonim Dror need to contact you by phone/email, and that you will be able to take responsibility for the Applicant at any time should they need to return home.

YesNo

Please provide details including dates that you will be out of the UK or unavailable to be contacted and the name of the person who will be available to pick up your child in your absence. Provide contact details in 3rd Nominated Contact. :

Is there a second Parent/Guardian for the Applicant?

YesNo

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

Is there a third Nominated Contact for the Applicant?

YesNo

Emergency Contact Person in Israel.

YesNo

Parent/Guardian #2 Contact Details

Title

First Name

Last Name

Marital Status

Relationship to the Applicant

Other

Relationship to Parent/Guardian 1

Mobile Telephone	Home Telephone	Work Telephone
Email Address

	Yes	No
Please confirm that the named Parent/Guardian #2 contact is the the legal guardian (with authority to complete this form on their child's behalf)
Please confirm that they will be in the UK throughout the programme should Habonim Dror need to contact they by phone/email, and that they will be able to take responsibility for the Applicant at any time should they need to return home

Please provide details including dates that they will be out of the UK or unavailable to be contacted:

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.

	Yes	No
I can confirm that the individual nominated as the Third Nominated Contact has been informed and agreed to the above requirements and conditions, and that in an emergency they may be contacted and need to respond during unsociable hours, and may be required to immediately collect your child.

Title

First Name

Last Name

Marital Status

Mobile Telephone

Home Telephone

Email Address

Relationship to the Applicant

Other

	Yes	No
Please confirm that they will be in the UK throughout the programme should Habonim Dror need to contact they by phone/email, and that they will be able to take responsibility for the Applicant at any time should they need to return home.

Please provide details including dates that you will be out of the UK or unavailable to be contacted:

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.

Full Name

Mobile Telephone

Home Telephone

Address

City in Israel

Relationship to the Applicant

Other

	Yes	No
This person will be in Israel throughout Israel Tour should the Habonim Dror need to contact them by phone/email. They will be able to take responsibility for the Applicant at any time.

If no, please provide details including dates that they will be out of the country or unavailable to be contacted:

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 note past behaviour and group management considerations will be taken into account when assigning rooms and groups.

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.

Friend #1

Friend #2

Friend #3

Is there any additional information that Habonim Dror should be made aware of before allocating the Applicant to their room? Please indicate in the space below.

Miscellaneous

T-Shirt Size: For some events, T-Shirts may be provided. Please indicate your preferred size

Swimming Ability

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
Allergies (Food & Non-food)

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

Describe 'Other Allergy'

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.

Signs and Symptoms of Allergic Reaction

How have past allergic reactions been treated?

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
Because of the Applicant's allergy/intolerance, buffet-style meals are problematic
The Applicant can consume foods that may "have been processed in the same factory as" the allergen

	Yes	No
Has the Applicant ever had to make an emergency hospital visit due to an allergic reaction?

	Yes	No
The Applicant has an EpiPen for their allergy

	I agree
Allergy Waiver

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.

I agree that the Applicant is able to monitor and manage their own condition.

I agree

At all times, the Applicant will ensure that they understand what they are consuming before doing so. Please note: Ingredients may be written in a different language and/or using different terminologies than is commonly used in the UK.

I agree

Medical and/or Behavioral 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

Name of Doctor

Name of Surgery

Surgery Telephone

Within the past six months, has the Applicant experienced any of the following:

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

Other condition (any medical, physical, mental, dental, optic, behavioral or any other form of condition)

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.

Please provide further details of all the conditions you selected that the Applicant has experienced. For each condition, please include: name of condition, how long the applicant has had this condition including dates, severity, treatment, medication prescribed, stability of condition Within the last 6 months (please ensure you include this information which is crucial for the medical insurers and may have other implications)

More than six months ago, has the Applicant experienced any of the following:

	None	Yes
Has the Applicant previously (more than six months ago) experienced any of the following:

Other condition (any medical, physical, mental, dental, optic, behavioral or any other form of condition)

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.

Please provide further details of all the conditions you selected that the Applicant has experienced. For each condition, please include: name of condition, how long the applicant has had this condition including dates, severity, treatment, medication prescribed, stability of condition Within the last 6 months (please ensure you include this information which is crucial for the medical insurers and may have other implications)

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 or complete it.. Habonim Dror will be in contact with you directly should they require more information.

Medication

	Yes	No
Is the Applicant currently taking any Medication that has been prescribed by their Doctor/GP/Specialist/Consultant (including alternative medication)?

If yes, please provide details of medication name, reason for prescription, frequency and dosage: (Please include all medication including antibiotics, the contraceptive pill, other medication etc.)

	Yes	No
Is the Applicant currently taking any non-prescribed Medication (including alternative medication)?

If yes, please provide details of non-prescribed medication name, reason for taking, frequency and dosage:

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.

I agree to the Madrichimot (Leaders) administering the following non-prescribed medication to the Applicant when deemed necessary for immediate medical needs (e.g. bad headache) at the Applicant's request or agreement. Please note, any fields which are unselected will not be administered to the Applicant.

If you wish for the Applicant to be issued with other non-prescribed medication by the Madrichimot (Leaders) when essential, please specify the product(s) below.

Further Medical Information

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

What is the Sex of the Applicant?

Please include any physical, mental, emotional or other medical health conditions that the Applicant has suffered from in the last three years including recurring illnesses or any significant ill health, or any other additional needs or concerns of any kind.

	Yes	No
Has the Applicant ever received counselling or psychotherapy, or psychiatric or psychological treatment or any related form of support?