Kibbutz Program Center Registration "Tikkun Olam in Tel Aviv / Jaffa" Registration Step 1 of 9 11% Personal Application QuestionnaireTerm*Spring 2013 (5 months)2012-2013 (10 months)Fall 2013 (5 months)Please note -- we usually begin processing applications for a term 5-8 months before the beginning of that term. If you do not see your desired term here, please check back later or contact us to find out when the application process for your term will begin.Track*Social ActionCoexistenceRoom*Single roomShared roomPersonal InformationFirst Name*Middle Initial*Last Name*Gender*Select . . .MaleFemaleOther (Please Specify)Other*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Country of Birth*Citizenship*Social Security/ Identification/ SS/ ID*Passport Number*Valid Until*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Contact InformationValid Until*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Street Address 1*Street Address 2*City*State/Province*Zip/Postal Code*Country*Primary Phone*Cell Phone*Email* Permanent Contact InformationSame as CurrentYesNoStreet Address 1Street Address 2CityState/ProvinceZIP/Postal CodeCountryHome PhoneCell PhoneEmail Family InformationParent/Guardian 1Parent*Select . . .MotherFatherGuardian/OtherName*Address*City*State/ProvinceZIP/Postal Code*Primary Phone*Secondary PhoneEmail Address Parent/Guardian 2Parent*Select . . .MotherFatherGuardian/OtherName*Address*City*State/ProvinceZIP/Postal Code*Primary Phone*Secondary PhoneEmail Address 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 ReligiousWhich of the following best describes your Jewish denominational identity*ConservativeOrthodoxReform ReconstructionistRenewalJust JewishNot applicable, I'm not JewishSynagogue AffiliationNameLocationRestrictions* No Requirements Kosher Vegetarian Shomer Shabbat General EducationCollege/University (list all undergraduate and graduate schools attended)Are you CURRENTLY*a college freshman (1st year)a college sophomore (2nd year)a college junior (3rd year)a college senior (4th year)a college student (5th year or beyond)studying for a Master’s degree (e.g. MA, MBA, MSW, MS)studying for a Doctoral degree (e.g. PhD, EdD)studying for a professional degree (e.g. MD, JD)working (primarily career-focused, e.g. a non-student)School 1Name of School*Location*Major/Minor/Degree*Dates Attended*Enable 2nd School Yes School 2Name of SchoolLocationMajor/Minor/DegreeDates AttendedEnable 3rd School Yes School 3Name of SchoolLocationMajor/Minor/DegreeDates AttendedJewish EducationElementary and SecondarySchool 1Name of SchoolLocationType of ProgramDates AttendedSchool 2Name of SchoolLocationType of ProgramDates AttendedEnable 3rd School Yes School 3Name of SchoolLocationType of ProgramDates AttendedUniversity Level Courses in Judaica or HebrewSchool 1Name of SchoolCourseDates AttendedSchool 2Name of SchoolCourseDates AttendedSchool 3Name of SchoolCourseDates AttendedInformal EducationList any specific experience you have had as a camper, youth group member, etc.Organization 1OrganizationLocationType of ProgramDates, AttendedEnable 2nd Organization Yes Organization 2OrganizationLocationType of ProgramDates, AttendedEnable 3rd Organization Yes Organization 3OrganizationLocationType of ProgramDates, Attended Previous Travel ExperienceIsrael List type of program, duration of visit, and dates tended.Overseas Other than Israel.Are you a past Birthright Israel participant?*YesNoDatesTrip OrganizerLanguage ProficiencyRate your proficiency level in speaking, reading and comprehending.English*Select . . .FluentConversationalSomewhat functionalA few words and phrasesNoneHebrew*Select . . .FluentConversationalSomewhat functionalA few words and phrasesNoneOther LanguagesLanguageProficiency*Select . . .FluentConversationalSomewhat functionalA few words and phrasesNoneLanguageProficiency*Select . . .FluentConversationalSomewhat functionalA few words and phrasesNoneHow did you learn about TIKKUN OLAM IN TEL AVIV-JAFFA?* 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*Select . . .MaleFemaleOther (Please Specify)Permanent 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* General 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 followingAsthma*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 TIKKUN OLAM IN TEL AVIV-JAFFA 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 TIKKUN OLAM IN TEL AVIV-JAFFA 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 TIKKUN OLAM IN TEL AVIV-JAFFA 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* Yes Essay Questions ALL 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 Tikkun Olam in Tel Aviv-Jaffa Group? 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 Vitae First Name*Last Name*Email* Upload Your ResumeAttach a file containing your resume or curriculum vitae (CV).