Apply - Darkaynu

Register to Elaine and Norm Brodsky Darkaynu Programs

To apply, please fill in the online application, or download and email or mail it back to us.
Our email address is: darkaynu@ots.org.il

Our mailing address is:

Darkaynu Programs
51 Leib Yaffe Street
Jerusalem 9339082
Israel

Before filling out the application please be in touch directly with the Darkaynu office at darkaynu@ots.org.il

Application Form

Applicant Information
Applicant's Name
First Last Legal Name
Applicant's Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address (if different than above)
Telephone:
Personal Phone
Work Phone
Cell Phone
Cell Phone:
Cell Phone Mother
Cell Phone Father
E-mail address:
Personal Email
Mother Email
Father Email
Date of Birth (Month/Day/Year)
Date Format: MM slash DD slash YYYY
Place of Birth
Citizenship
Social Security Number
Passport Number
Country Issuing Passport
Current School/Program
FATHER INFO:
Name
First Last
Date of Birth
Occupation
Citizen
Address (if different from applicant)
Business Phone
MOTHER INFO:
Name
First Last
Maiden Name
Date of Birth
Occupation
Citizen
Address (if different from applicant)
Business Phone
Are parents: married, divorced, widowed or separated?
Applicant's name: (please print)
First Last
If you live with a guardian, please write his/her name and relationship to you:

Siblings

Name	Age	School/Occupation	Yeshiva attended in Israel (if applicable)

Israeli Citizenship:
I have Israeli citizenship
- Yes
- No
My Teudat Zehut number is:
I was born in Israel
- Yes
- No
One or both of my parents are Israeli citizens
- Yes
- No
Education

Elementary Schools

Name	Location	Attended (from-to)

Secondary Schools

Name	Location	Attended (from-to)

Jewish Schools (if not included above)
Hebrew Skills: Please rate yourself (circle or enter a number) (1=none, 5 =fluent)
Read with vowels
Please enter a number from 1 to 5.
Read w/o vowels
Please enter a number from 1 to 5.
Understand
Please enter a number from 1 to 5.
Speak
Please enter a number from 1 to 5.
Write
Please enter a number from 1 to 5.
What Torah subjects have you studied? (Give Details)
Applicant's name: (please print)
First Last
Extra-Curricular Activities:
Describe your extracurricular activities in and out of school: List programs and organizations you have been involved with
What did you do the last three summers?
Previous visits to Israel (programs)
Work/Volunteer Experience:
FAMILY OR CLOSE FRIENDS IN ISRAEL (IF ANY):

Add as many as you have:

Name	Address	Telephone	Relationship

Consent
I certify that, to the best of my knowledge, all the above information istrue.
- I accept
Signature of Applicant
Reset
Date
Date
Signature of Parent/Guardian
Reset
Date
EMERGENCY CONTACT FORM:
Name
Applicant's name
Birth Date
Applicant's Home Address:
City State / Province / Region ZIP / Postal Code Country
Phone

In case of an emergency, please contact:

Name	Relationship to participant	Phone	Cell

Physician to contact in case of an emergency:
Name
Name of Physician to Contact
Relationship to participant
Phone
Cell
Address
City State / Province / Region ZIP / Postal Code
Insurance Information:
Name
Name of Cardholder
Relationship to Participant
Insurance Company
ID #
Group #
Coverage includes:
- Prescription Drugs
- out-of-Country
Please be sure to include a copy of your child's insurance card with this
ESSAY
Please write a short essay or provide a video presentation on the topic below.
WHAT I HOPE TO GAIN FROM MY YEAR AT DARKAYNU
Please remember to include the application fee and two photographs. Please insure that your application and two letters of recommendation arrive prior to the deadline.

Medical Form

PERSONAL HEALTH HISTORY
Applicant's name (please print)
First Last
Have you or any members of your family suffered from:
- tuberculosis
- epilepsy
- emotional disturbances
- heart disease
- asthma
- diabetes
- digestive tract diseases
- other diseases
Details
Please check appropriate answer below. If yes, give details Use separate sheet, if necessary.
Please list any hospitalizations and diagnosis?
- Yes
- No
Details and Dates:
Are you currently taking any medication?
- Yes
- No
Details and Dates:
Are you allergic to any medications?
- Yes
- No
If yes, indicate which medications:
List any other allergies
Have you ever received psychological counseling?
- Yes
- No
Details and Dates:
Do you have any physical limitations?
- Yes
- No
Details and Dates:

Contact in Israel to notify in case of an emergency:

Name	Cell	Relationship

This information will be kept strictly confidential
Has your child ever had:
- Concussion, or been knocked out?
- Fainting?
- Convulsions?
- Head or neck injury?
- Do you wear glasses, contacts, other?
- Any broken bones?
- Dislocation or other problems?
- Serious foot problem?
- Back injury or frequent backaches?
- Ankle or knee injury problems?
- Other joint problems?
- Do you have a hernia?
- Have you had diabetes?
- Single illness for more than 10 days?
- Easy bruising or bleeding tendency?
- Anemia?
- Asthma?
- Bee sting allergy?
- Penicillin allergy?
- Hay fever allergy?
- Other allergies?
- Heart trouble or murmurs?
- High blood pressure?
- Chest pain or faintness with exercise?
- Kidney problems?
- German measles?
- Measles?
- Pneumonia?
- Chicken Pox?
- Sleep Walking?
- Hearing loss or deafness?
- Perforated eardrum or "tubes" in ears?
- Concussion or been knocked out?
- For Girls Only: Any menstrual problems?
- Do you miss school because of your period?
PLEASE PROVIDE AS MUCH DETAILED INFORMATION AS POSSIBLE THIS WILL MAXIMIZE OUR ABILITY TO WORK EFFECTIVELY WITH YOUR CHILD
1. Does your child have any specific medical problems? Please specify. Include allergies to insect bites.
2. Does your child have any special eating habits or allergies? Please specify
3. Does your child have any sleeping habits we should know about?
4. Does your child have any unusual fears or anxiety? Please specify. If so, how are they handled at home and at work or school?
5. Are there any behavioral challenges (i.e temper) we should aware of? How do you deal with them?
6. Please note other information we should aware of regarding your child. Remember, information that seems insignificant to you may be very important when working with your child
EMERGENCY MEDICAL FORM
(This information will be kept strictly confidential)
Name
Name of Student Father's Name Mother's Name
Parents are married
- divorced
- separated
- widowed
Address:
Phone no.
Date of Birth
Passport no.
Place of Birth
PERSON IN ISRAEL TO NOTIFY IN CASE OF EMERGENCY:
Name
Name
Relationship to Student
Address
Phone

Height	Weight

2. Have you or any member of your family suffered from: tuberculosis, epilepsy, emotional disturbances, heart diseases, asthma, diabetes, digestive tract diseases, other diseases. Please check appropriate answer below. If yes, give details, Use separate sheet ifnecessary.
- Yes
- No
Details
3. Please list any hospitalizations and diagnosis:
- Yes
- No
Details and dates
4. Have you ever received psychological counseling
- NO
- YES
Details
5. Are you allergic to any medications:
- Yes
- No
If yes, indicate which medications:
6. List any other allergies:
MEDICAL EXAMINATION TO BE COMPLETED BY PHYSICIAN
Student

Height	Weight

Vision	Hearing

2. General Examination

Heart

Normal	Deviation from Normal

Lungs, Chest

Normal	Deviation from Normal

Hernia

Normal	Deviation from Normal

Hemoglobin

Normal	Deviation from Normal

Mouth, Throat

Normal	Deviation from Normal

Skin

Normal	Deviation from Normal

Spine

Normal	Deviation from Normal

Feet

Normal	Deviation from Normal

Nervous System

Normal	Deviation from Normal

Allergies

Normal	Deviation from Normal

Menstrual History

Normal	Deviation from Normal

Other remarks
3. a) Is the student currently receiving any medications? If so, please attach statement of such medications with dosage and directions.

b) List any medication that the student has taken regularly at any point over the last three years
4. Has the student manifested any signs of an eating/dietary disorder?
- Yes
- No
Details
5. Does the student have any physical limitations: (
- Yes
- No
6. Date of last tetanus immunization :
I have examined the above named student and DO consider him/her physically and emotionally able to participate in your program in Israel
Name of Physician:
(please print)
Address
Date
Signature
Reset
To the best of my knowledge all the above information is both accurate and complete
Student Signature
Reset
Applicant's name
First Last
(please print)
- Prescription
- Non prescription Medications
If your child is not on any prescription medications please go straight to the next page - Part B
A. Prescription Medication

Please fill out one of these forms for EACH medication. You may use the back of the form if more room is needed.

Please provide us with as much information as possible pertaining to your child’s medications as it can be a direct effect on the success of your child in the program
1 a. What is the name and dosage of the medication you child is currently taking?
b. How often? What time of day does your child take this medication
c. Does it say the same thing on the bottle? If no, please explain:
- Yes
- No
d. What is the medication for (what is it supposed to do)?
e. Who prescribed the medication?
f. How long has your child been on the medication for?
g. Does the medication interact with other medications or something else?
h. Does the medication have any side effects that your child experiences?
2.a. How does your child take the medication?
b. Is it taken independently? Or is a reminder needed?
c. Has the medication ever purposely not been taken
3. What is the procedure if a dose is missed?
4. What is your plan for filling the medication during your child’s year in Israel?
(Are you sending replacement, are we filling the prescription- does it have refills on the bottle or are you sending a prescription?
B. Non- prescription medications

The better prepared we are even for the ‘little’ things, the more we can be of assistance to your child throughout her year and help her gain the utmost from all of her experiences.
1. Does your child get sick often? Headaches, stomach aches, menstrual cramps, colds, coughs, or other…
2. What do you suggest your child should do when he/she is not feeling well?
3. What medications does your child take for the above listed ailments?
4. Do you give your child aspirin, Tylenol, Advil? Which seems to have the best effect?
5. Can your child swallow pills, or if not how does he/she take medication?
For Girls Only:
6. What happens when your daughter has her period? Does she need medication? Mood? PMS ? Cleanliness? Etc.
7. Other information you think we should know:

Application Form

Applicant Information

Telephone:

Cell Phone:

E-mail address:

FATHER INFO:

MOTHER INFO:

Israeli Citizenship:

Education

Extra-Curricular Activities:

FAMILY OR CLOSE FRIENDS IN ISRAEL (IF ANY):

Consent

EMERGENCY CONTACT FORM:

Physician to contact in case of an emergency:

Insurance Information:

ESSAY

Medical Form

PERSONAL HEALTH HISTORY

EMERGENCY MEDICAL FORM

PERSON IN ISRAEL TO NOTIFY IN CASE OF EMERGENCY:

MEDICAL EXAMINATION TO BE COMPLETED BY PHYSICIAN

For Girls Only:

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