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

  • Telephone:

  • Cell Phone:

  • E-mail address:

  • Date Format: MM slash DD slash YYYY
  • FATHER INFO:

  • MOTHER INFO:

  • NameAgeSchool/OccupationYeshiva attended in Israel (if applicable) 
  • Israeli Citizenship:

  • Education

  • NameLocationAttended (from-to) 
  • NameLocationAttended (from-to) 
  • Hebrew Skills: Please rate yourself (circle or enter a number) (1=none, 5 =fluent)
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Please enter a number from 1 to 5.
  • Extra-Curricular Activities:

  • FAMILY OR CLOSE FRIENDS IN ISRAEL (IF ANY):

  • NameAddressTelephoneRelationship 
  • Consent

  • EMERGENCY CONTACT FORM:

  • NameRelationship to participantPhoneCell 
  • Physician to contact in case of an emergency:

  • Insurance Information:

  • 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.
  • 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

  • Please check appropriate answer below. If yes, give details Use separate sheet, if necessary.
  • NameCellRelationship 
  • This information will be kept strictly confidential
  • PLEASE PROVIDE AS MUCH DETAILED INFORMATION AS POSSIBLE THIS WILL MAXIMIZE OUR ABILITY TO WORK EFFECTIVELY WITH YOUR CHILD
  • EMERGENCY MEDICAL FORM

    (This information will be kept strictly confidential)
  • PERSON IN ISRAEL TO NOTIFY IN CASE OF EMERGENCY:

  • HeightWeight 
  • MEDICAL EXAMINATION TO BE COMPLETED BY PHYSICIAN

  • HeightWeight 
  • VisionHearing 
  • 2. General Examination
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • NormalDeviation from Normal 
  • 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
  • I have examined the above named student and DO consider him/her physically and emotionally able to participate in your program in Israel
  • To the best of my knowledge all the above information is both accurate and complete
  • (please print)
  • 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

  • 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.

  • For Girls Only: