Application Form For Non-Israelis

APPLICATION (to be completed by applicant)

All volunteers are subject to army security clearance.

Last Name: _______________________ First Name: ______________________ Sex M F

Date of Birth: ___/___/___

Passport Number: _________________ Exp. Date: __________ Family Status: ___________________________

Religion:___________________ Address: ____________________________________________________________________

City: ________________________ State: ______ Country _____ Zip: ________________ Telephone: (____) ________ –

_______________ e-mail: _______________________________________________

What countries have you visited in the last 5 years?________________________________

Occupation:_________________________________________________________________

Employer (name, address, phone)_______________________________________________

Contact in event of emergency (Name): _______________________________________

Telephone: (____) ________ – _______________ e-mail: __________________________

Program Dates: from _________ to _________ Arrival Date (in Israel): _____________________

Arrival Time: ______________ AM PM Airline: ______________ Flight # _______________

Arrival Day: Su M T W T F S Departure Date (from Israel)_____________________________

Repeat Volunteer:  Yes            No

When were you last at Sar-El?

Joining Sar-El on arrival date?   Yes   No                 If no join date: ___________________________

Flights are met on Sun during normal working hours. (Arrival policies subject to revision) The following additional items must accompany your application documents: Reference letter from your clergy or a leader in your community; a copy of your passport picture page; a copy of your medical travel insurance policy**BRING TO ISRAEL 3 copies of all of the following documents: medical form completed by your physician and all specialists you are currently seeing, passport, medical insurance card or policy in effect during your program, application cover sheet, waiver.

Registration Fee: $110____ $60 ______ (if repeating within 1 year or under 25) To be paid in Cash only in person to Sar-El representative in Israel.

Waiver and Release/Terms and Conditions Sar-El Volunteers for Israel, hereinafter referred to as “Sar-El” reserves the right to accept or not to accept any person as a member of the program. Sar-El reserves the right to cancel at any time, and to reject any applicant for any reason(s) it deems appropriate. Participants may be immediately dismissed from the program in Israel for proselytizing, use of alcohol or drugs, or other behavior deemed to be dangerous to persons, property, or security. Proselytizing includes discussing your religion with someone who doesn’t share your same beliefs in a manner which is intended to be persuasive or which is offensive. This also includes distributing any religious literature. All inappropriate behavior will not be tolerated. This includes sexual harassment or aggressive behavior. Dismissal from the program will result in immediate removal from the IDF Base (or other program location), and the participant will be solely responsible for expenses incurred thereafter, including but not limited to lodging, transportation, and meals. In addition, program fees paid will not be refunded. I hereby agree to participate in the Sar-El (hereafter, “the Program”) upon the express undertakings and acceptances which follow. Wherever the name “Sar-El” is used in this document, it shall be taken to mean Sar-El and any co-sponsors of the Program in whole or in part, and their agents, servants and employees.

DECLARATION OF HEALTH

I have been advised that the Program may call at times for vigorous exertion and physical effort and under spartan living conditions. I declare that I am in good physical condition and mental health, capable of participating in the Program and that, as may have been reasonably advisable, I have obtained the confirmation of my physician for these purposes. Should it become necessary, this document shall constitute a release of my medical examination records to the appropriate medical personnel in Israel. INSURANCE Prior to my entering the Program, I agree to purchase at my expense accident and health insurance covering medical and hospitalization expenses while in Israel as required by the Program. I understand and agree that I am responsible for any medical bills (including doctors’ visits, hospitalization, accidents) incurred while I am in the Sar-El Program. I will pay the cost of the treatment and will settle expenses with my insurance company when I return home unless the insurance company agrees to pay the bills directly. (I will have a credit card or sufficient cash to do this).

ASSUMPTION OF RISK AND WAIVER OF LIABILITY

Having been informed of risks inherent in the Program, I declare that I assume all risks involved in my participation in the Program and waive all claims of responsibility in Sar-El for any losses or damage except as may be caused by its gross negligence or willful misconduct. I expressly accept that Sar-El shall not be deemed responsible for transportation, accommodations, tour programs or other services while I am off the base to which I am assigned unless such off base event is required by the Program. I agree to hold Sar-El exempt from any and all claims which may be brought against Sar-El on account of misconduct on my part. In participating in the Sar-El Volunteers for Israel, I verify that I have read and accept these terms and conditions, and agree that they shall be binding on me. I also affirm that I have no intention of serving in, joining, or swearing allegiance to the Israel Defense Forces unless this is disclosed in advance. I have no criminal or police record except the following:

Signature _____________________________________ Date ______________________

Please attach a copy of your medical insurance card NOTE: Medicare not valid outside USA

MEDICAL FORM PART 1 of 2 (to be completed by licensed physician)

TO THE EXAMINING PHYSICIAN: Please take this application seriously. Ours is a rigorous three-week work program which involves spartan living conditions with no central heat or air conditioning, possibly working in the hot sun, repetitive lifting/twisting/bending, and long hours on one’s feet. Your medical evaluation of the applicant’s physical condition and stable positive mental outlook is essential to us in determining whether or not to accept the applicant into our program. This information is also vital to enable medical professionals in Israel to appropriately address medical emergencies that this individual may face during the volunteer program. YOU WILL BE DOING A GREAT DISSERVICE TO YOUR PATIENT IF YOU APPROVE SOMEONE WHO HAS MEDICAL OR PSYCHOLOGICAL PROBLEMS THAT MAY CAUSE HARM TO THIS INDIVIDUAL OR OTHERS BY UNDERTAKING THIS WORK EFFORT.

Patient Last Name _______________________ First name ______________ Age ____

Sar-El Volunteers for Israel Program target date ________________________

How long has the applicant been a patient of your practice? ___________________

MEDICAL HISTORY

Allergies: Medications: Surgeries: History of severe injuries: Heart disease_____ Angina _____ Rheumatic fever _____ Hypertension _____ Congestive failure _____ Diabetes _______ Emphysema_____ Asthma _____ COPD _____ Ulcers/GI bleed _____ Diverticulitis_____ Kidney stone ______ Osteoporosis _____ Arthritis _____ Migraine _____ Seizures _____ Cancer ______ Hepatitis _____

MEDICAL FORM PART 2 of 2

PHYSICAL EXAMINATION (note any deviations from normal): Height: Heart: Mouth/Teeth: Weight: Head: Pulse: Abdomen: Lungs: Throat/Thyroid: GU: Eyes: Skin: Extremities: Hearing: Neuro: Other: Eyes: B/P: Can applicant do manual labor? ____ Lift 20 pounds?____ Bend without pain? ____

Any history of back injury/problems? ______________________________________

Will change in diet cause concern for health

problems?________________________ (For example, Israeli food is generally higher in salt content.)

PSYCHOLOGICAL PROFILE:  Conditions imposed by a foreign work program include lengthy absence from family and home, group living situation, new social contacts, and adjustment to cultural differences. Please evaluate psychological and emotional stability:

Is the applicant a flexible and agreeable person?________________________________

Is the applicant capable of working with others?________________________________

Any history of mental illness, significant depression, bipolar disorder?______________

Any history of being treated by a psychiatrist/psychologist?______________________

Use of tranquilizers, anti-psychotics, illicit drugs?_______________________________

PLEASE DO NOT APPROVE ANYONE WHO IS NOT CAPABLE OF WALKING LONG DISTANCES IN HOT, HUMID WEATHER AND WORKING A FULL DAY STANDING

I have examined the above named applicant and ___ Do ___ Do not consider him/her physically and emotionally qualified to participate in a rigorous Sar-El Volunteers for Israel work program.

Physician’s Signature __________________________________ Date ____________

PLEASE PRINT Physician’s Name (print) _________________________________________________

Address_________________________ City _________________ St _____ Zip __________ Telephone: ( )

______________________ Fax # ( ) _________________________

VOLUNTEERS WITH MEDICAL CONDITIONS THAT PUT THEMSELVES AT RISK OR WHICH BURDEN OTHER VOLUNTEERS OR STAFF MEMBERS CANNOT PARTICIPATE IN SAR-EL OR MAY BE ASKED TO LEAVE THE PROGRAM.

HTMLine - בניית אתרים