Kibbutz Program Center Registration "Bina's Social Action Gap Year" Registration Step 1 of 9 11% Personal InformationFirst Name*Last Name*Gender*MaleFemaleDate of Birth* Country of Birth*Citizenship*Social Security/ Identification / SS / ID*Passport Number*Valid Until*Current Contact InformationValid Until*Number/Street*City*State/Provice*Zip/Postal Code*Country*Primary Phone*Secondary PhoneEmail* Permanent Contact InformationSame as Current*YesNoNumber/Street*City*State/Provice*Zip/Postal Code*Country*Home Phone*Cell Phone*Email* Family GuardianParent/Guardian 1Parent*MotherFatherGuardian/OtherFull Name*Address*City*State/Province*ZIP/Postal Code*Primary Phone*Secondary PhoneEmail Parent/Guardian 2Parent*MotherFatherGuardian/OtherFull Name*Address*City*State/Province*ZIP/Postal Code*Primary Phone*Secondary PhoneEmail SiblingsNumberNames & Ages One or both of my parents is/are either Israeli-born or Israeli Citizen(s)*YesNoIf so, which parent(s)? Mother Father Have you ever been arrested, charged, or convicted by a law enforcement authority for any violation of a law or ordinance (other than a minor traffic violation)?*YesNoIf yes, please explain ReligiousReligious Affiliation*UnaffiliatedConservativeOrthodoxReconstructionistReformSynagogue AffiliationNameLocationRestrictions* No Requirements Kosher Vegetarian Shomer Shabbat Secondary EducationSecondary Education* Enable 2nd School Enable 3rd School School 1Name of School*Location*Dates Attended*dd/mm/yySchool 2Name of SchoolLocationDates Attendeddd/mm/yySchool 3Name of SchoolLocationDates Attendeddd/mm/yyJewish EducationJewish Education Enable 2nd School Enable 3rd School School 1Name of SchoolLocationType of ProgramDates Attendeddd/mm/yySchool 2Name of SchoolLocationType of ProgramDates Attendeddd/mm/yySchool 3Name of SchoolLocationType of ProgramDates Attendeddd/mm/yyInformal EducationInformal Education Enable 2nd Organization Enable 3rd Organization Organization 1OrganizationLocationType of ProgramDates Attendeddd/mm/yyOrganization 2OrganizationLocationType of ProgramDates Attendeddd/mm/yyOrganization 3OrganizationLocationType of ProgramDates Attendeddd/mm/yy Previous Travel ExperienceIsrael List type of program, duration of visit, and dates tended.Overseas Other than Israel.Datesdd/mm/yyTrip OrganizerLanguage ProficiencyRate your proficiency level in speaking, reading and comprehending.English*FluentConversationalSomewhat functionalA few words and phrasesNoneHebrew*FluentConversationalSomewhat functionalA few words and phrasesNoneOther LanguageLanguage 1Proficiency*FluentConversationalSomewhat functionalA few words and phrasesNoneLanguage 2Proficiency*FluentConversationalSomewhat functionalA few words and phrasesNoneHow did you learn about BINA's Gap Year Program?* Please be specific as possible.I certify that all statements and details in this questionnaire are true to the best of my knowledge* I Agree Personal Health FormFirst Name*Last Name*Gender*MaleFemalePermanent AddressAddress*City*State/Province*ZIP/Postal Code*Phone*Alternate PhoneEmail* Family Medical HistoryHave any of your immediate family members suffered from any diseases or conditions that about which we should be made aware?*YesNoIf yes, please explain Is your biological family history unknown?*YesNoIf yes, please explain Emergency ContactPlease list someone other than a parent or guardianFirst Name*Last Name*Phone*Relationship to Participant* Personal Health HistoryGeneral Medical InformationHave you ever been treated for any major physical ailment?*YesNoDo you require any special medical, dental or dietetic services or attention?*YesNoHave you ever had asthma or other allergic disorders?*YesNoHave you ever had surgery or any major hospitalization?*YesNoHave you ever been treated by a mental health professional?*YesNoIf you have answered "Yes" to any of the above, please list dates and explain briefly Health RecordPlease note: "Yes" responses will NOT disqualify you from participation in Tikkun Olam in Tel Aviv-Jaffa. We trust that you will answer these questions honestly and in full. All of the information must be filled out completely and will be treated confidentially. Please select "Yes" if you have ever had, or currently have any of the following:Asthma*YesNoCigarette smoking*YesNoHeadaches or migraines*YesNoAllergies*YesNoBronchitis*YesNoHeart trouble*YesNoCancer*YesNoKidney trouble*YesNoRecurrent back pain*YesNoAbdominal pain*YesNoHernia*YesNoUlcer or gastritis*YesNoIrritable bowel syndrome (IBS)*YesNoInflammatory disease*YesNoLactose intolerance*YesNoChicken pox*YesNoInsect sting reactivity*YesNoConvulsions Or seizures*YesNoMononucleosis*YesNoMedication intolerance*YesNoDiabetes*YesNoPneumonia/chronic bronchitis*YesNoEar infections*YesNoArthritis*YesNoEye trouble*YesNoFainting*YesNoSleep walking*YesNoFrequent colds*YesNoEndocrine disorder*YesNoTuberculosis*YesNoEating disorder*YesNoAlcohol or drug use*YesNoDepression*YesNoAccidents/fractures*YesNoOperations*YesNoAppendectomy*YesNoIf you have answered "Yes" to any of the above, please explain Indicate to which ailment you are referring, and please list dates.Are you currently taking any medication?*YesNoIf so, please state the name(s) of the medication(s) and the condition it is treating Applicant StatementI hereby certify that, to the best of my knowledge, the above medical form is complete in all its details, and I fully realize that any condition, mental or physical, that I am found to have that originated prior to my arrival in Israel, and which is not described in full in this form or in any accompanying letter, will be due cause for my return to my country of origin, or treatment in Israel solely at my expense, and taht the BINA's GAP YEAR Program and its representatives in Israel have neither responsibility nor liability arising out of such conditions. I also realize that the medical coverage provided by BINA's GAP YEAR does not include dental treatment of any form whatsoever, or eyeglasses. All medications that I take regularly are at my own expense, and have been detailed in this form and in accompanying letters. I give my full permission for all treatment of any nature deemed necessary by doctors in Israel to be extended to me within the framework of the Medical Services of the BINA's GAP YEAR representatives in Israel. I am aware that usage or involvement with illegal drugs or narcotics or any other anti-social behavior may be cause for immediate dismissal from the program, and that I will be returned to my home country at my own expense.I agree to the conditions stated above*YesNo Essay QuestionsALL QUESTIONS MUST BE ANSWERED IN FULL for your application to be considered! You may enter your responses in the text fields below or upload a text document (such as Microsoft Word, Open Office, etc.) using the provided field. Each essay should be no more than 500 words (2 full pages, 12-point font, double-spaced).First Name*Last Name*Email Address* Submit Using This Form1. What Good Virtues Do You Bring With You To The Bina's gap year program in Tel Aviv? 2. What do you hope to gain from the experience and from the group? 3. What are the things that might make this experience difficult for you? 4. What do you see as the most exciting and/or valuable part of the program for you? Submit A Text DocumentUploadMicrosoft Word, Open Office and PDF formats are acceptable. Please have all 4 essay answers contained in one file. Resume / Curriculum VitaeFirst Name*Last Name*Email* Upload Your Resume*Attach a file containing your resume or curriculum vitae (CV).