Application Form For Israeli Citizens

SAR EL APPLICATION FOR ISRAELI CITIZENS

(Note: All volunteers are subject to army security clearance)

Last Name: _______________________ First Name: ______________________

Sex: M   F   Date of Birth: ___/___/___ 

Teudat Zehut Number: _________________   Date of Aliyah:  ___/___/___   Family Status: ________ Religion: _________ Address: ____________________________________________________________________

City: ________________________   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 __________________

The following additional items must accompany your application documents: 1 copy of your teudat zehut picture page and of your Kupat Cholim medical card

**FIRST TIME VOLUNTEERS: we also require 1 signed copy of  this application including the medical form completed by your physician and all specialists you are currently seeing.

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, any 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. I understand and agree that I am responsible for any medical bills (including doctors’ visits, hospitalization, and accidents) incurred while I am in the Sar-El Program.

 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 have no criminal or police record. 

Signature _____________________________________

Date ______________________

 

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, up to 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, army food may be 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 _________________ Zip __________ Telephone: 

______________________ Fax #or email: _________________________

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