Register to Elaine and Norm Brodsky Darkaynu ProgramsTo 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 Programs51 Leib Yaffe StreetJerusalem 9339082Israel Before filling out the application please be in touch directly with the Darkaynu office at darkaynu@ots.org.il Download Application Application Form Applicant InformationApplicant's Name First Last Legal Name Applicant's Home Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mailing Address (if different than above) Telephone:Personal PhoneWork PhoneCell PhoneCell Phone:Cell Phone MotherCell Phone FatherE-mail address:Personal Email Mother Email Father Email Date of Birth (Month/Day/Year) Date Format: MM slash DD slash YYYY Place of BirthCitizenshipSocial Security NumberPassport NumberCountry Issuing PassportCurrent School/ProgramFATHER INFO:Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920OccupationCitizenAddress (if different from applicant)Business PhoneMOTHER INFO:Name First Last Maiden NameDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920OccupationCitizenAddress (if different from applicant)Business PhoneAre 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:SiblingsNameAgeSchool/OccupationYeshiva attended in Israel (if applicable) Israeli Citizenship:I have Israeli citizenshipYesNoMy Teudat Zehut number is:I was born in IsraelYesNoOne or both of my parents are Israeli citizensYesNoEducationElementary SchoolsNameLocationAttended (from-to) Secondary SchoolsNameLocationAttended (from-to) Jewish Schools (if not included above)Hebrew Skills: Please rate yourself (circle or enter a number) (1=none, 5 =fluent)Read with vowelsPlease enter a number from 1 to 5.Read w/o vowelsPlease enter a number from 1 to 5.UnderstandPlease enter a number from 1 to 5.SpeakPlease enter a number from 1 to 5.WritePlease 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 withWhat 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:NameAddressTelephoneRelationship ConsentI certify that, to the best of my knowledge, all the above information istrue. I accept Signature of ApplicantReset DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature of Parent/GuardianReset DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EMERGENCY CONTACT FORM:Name Applicant's name Birth DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Applicant's Home Address: City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneIn case of an emergency, please contact:NameRelationship to participantPhoneCell Physician to contact in case of an emergency:Name Name of Physician to Contact Relationship to participantPhoneCellAddress City State / Province / Region ZIP / Postal Code Insurance Information:Name Name of Cardholder Relationship to ParticipantInsurance CompanyID #Group #Coverage includes: Prescription Drugs out-of-Country Please be sure to include a copy of your child's insurance card with thisESSAYPlease write a short essay or provide a video presentation on the topic below. WHAT I HOPE TO GAIN FROM MY YEAR AT DARKAYNUPlease 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 HISTORYApplicant'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 DetailsPlease 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 allergiesHave 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:NameCellRelationship This information will be kept strictly confidentialHas 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 CHILD1. 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 specify3. 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 childEMERGENCY 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 BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Passport no.Place of BirthPERSON IN ISRAEL TO NOTIFY IN CASE OF EMERGENCY:Name Name Relationship to StudentAddressPhone1HeightWeight 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 Details3. Please list any hospitalizations and diagnosis: Yes No Details and dates4. Have you ever received psychological counseling NO YES Details5. Are you allergic to any medications: Yes No If yes, indicate which medications:6. List any other allergies:MEDICAL EXAMINATION TO BE COMPLETED BY PHYSICIANStudentHeightWeight 1.VisionHearing 2. General Examination HeartNormalDeviation from Normal Lungs, ChestNormalDeviation from Normal HerniaNormalDeviation from Normal HemoglobinNormalDeviation from Normal Mouth, ThroatNormalDeviation from Normal SkinNormalDeviation from Normal SpineNormalDeviation from Normal FeetNormalDeviation from Normal Nervous SystemNormalDeviation from Normal AllergiesNormalDeviation from Normal Menstrual HistoryNormalDeviation from Normal Other remarks3. 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 years4. Has the student manifested any signs of an eating/dietary disorder? Yes No Details5. 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 IsraelName of Physician: (please print) AddressDateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SignatureReset To the best of my knowledge all the above information is both accurate and complete Student SignatureReset Applicant's name First Last (please print)PrescriptionNon prescription MedicationsIf 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 program1 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 medicationc. 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 taken3. 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: