ECJS birthright Israel Emergency Form

Please print, fill out and sign this form.

Participant Name:
Home address:
City:
Zip:
Country:
Name of School:
Home phone:
School Phone:
Mobile:
Passport number:
Age:
Emergency contact information
1.
Name:
Home Phone:
Work Phone:
Cell:
Relationship:
2.
Name:
Home Phone:
Work Phone:
Cell:
Relationship:
Name of emergency contact in Israel, if available:
1.
Name:
Phone:
Relationship:
2.
Name:
Phone:
Relationship:
ECJS birthright Israel Emergency Form Required Medical Information Note: Omitting information can place you at risk. Medical information will be kept confidential and shared only if necessary with relevant medical personnel. 1) Please list any medical/emotional conditions you currently have or have had in the past. 2) Are you currently taking any medications? If so, which medications and for what condition (s)? 3) Please list any restrictions on activities, i.e. swimming, hiking, etc. Other: 1) Do you have any dietary restrictions, i.e. vegetarian? 2) Do you have any roommate preferences? 3) Is there anything else important you feel we should know about you? Signed_______________________________ Date_____________