Israel Bound Health History Form

Participant Name*

First Last

Parent/Legal Guardian Email Address*

Medical Insurance Information

Participation in the program is contingent upon the participant having medical insurance which covers pre-existing conditions that is valid in Israel. Participant is covered under:

Insurance Company*

Policy Number*

Group Number*

COVID-19 Vaccine Record

Please upload a copy of your CDC vaccine card, front and back. *A Note About Covid-19: Rules and regulations surrounding COVID-19 vary by location in the US, and between the US and Israel. At this time, we are collecting COVID-19 vaccine information and require that all Israel Bound teens are vaccinated and boosted. Israel Bound and the Jewish Federation of St. Louis recognize that this is a very fluid situation. As we get closer to our departure date, we will be issuing a document provided by our tour provider, Authentic Israel, outlining the current Covid-19 conditions in Israel, and any restrictions, protocols or vaccine mandates issued by the Israeli government.

Upload

Drop files here or

Accepted file types: jpeg, png, pdf, heic, Max. file size: 24 MB, Max. files: 2.

General Health History

Has the participant ever been hospitalized?*

Yes
No

Has the participant ever been diagnosed with a medical condition?*

Yes
No

Has the participant ever had a major injury as a result of an accident?*

Yes
No

Does the participant have a form of disability or impediment?*

Yes
No

If the answer was “Yes” to any of the above, please elaborate as follows:*

Please list any dietary restrictions and any food/medicinal allergies:

Please list any prescription medication used and condition treated:

Please list any activities that should restricted:

If there is a history of eating disorders, please explain:

If there is a history of behavioral disorders, please specify:

Please list anything else we may need to know:

Mental Health History

Has your child been under any psychological treatment or form of counseling? Please explain:

Your response in no way means that your son/daughter will not be accepted to the program. This information gives us the ability to deal with any situations that may arise on the program. Inaccurate information inevitably harms the participant. We require honest and factual information to appropriately determine your child’s needs.

Medical Authorization/Consent to Treat/Medical Ability to Participate

Consent of Parent/Legal Guardian*

I agree to the policy.

I/we am/are the parent or legal guardian having custody of a minor child. As such I/we hereby authorize and appoint Israel Bound, its program provider, Authentic Israel, their employees, trustees, officers, volunteers, advisors, parent/legal guardian or other chaperones, administrators, faculty or representatives, and their successors and assigns (“Program Staff”), in whose care the minor child has been entrusted, as my agent to act for me/us with respect to my/our minor child and in my/our name in any way I/we could act in person to make any and all decisions for me/us with respect to my/our minor child, concerning my/our minor child’s personal care, medical treatment, hospitalization and health care and to require, authorize, withhold or withdraw any type of medical treatment or procedure, including X-ray examination, anesthetic, medical or surgical diagnosis or treatment which may be rendered to my/our minor child under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state or country, whichever is applicable, in which treatment is sought. Program Staff shall have the same access to my/our minor child’s medical records that I/we have, including the right to disclose the contents to others.
I/we hereby represent that our child is physically and mentally able to participate in the Program and that my/our minor child has had or will have, any necessary examinations prior to joining and/or participating. I/we acknowledge that Program Staff is relying upon these assurances. I/we further acknowledge that it is our responsibility to provide Program Staff with written updated information as necessary and/or as requested.
I/we, the undersigned parent or legal guardian of the minor child named above acknowledge that I/we have reviewed the above and confirm that the information is true and correct and that I/we have the authority to execute this MEDICAL AUTHORIZATION/CONSENT TO TREAT/MEDICAL ABILITY TO PARTICIPATE.

Signature of Parent/Legal Guardian*

A typed signature is considered legally binding.

Name

This field is for validation purposes and should be left unchanged.

All information is kept strictly confidential.

Medical Insurance Information

COVID-19 Vaccine Record

General Health History

Mental Health History

Medical Authorization/Consent to Treat/Medical Ability to Participate

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Israel Bound Health History Form

All information is kept strictly confidential.

Medical Insurance Information

COVID-19 Vaccine Record

General Health History

Mental Health History

Medical Authorization/Consent to Treat/Medical Ability to Participate

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