TEST

Yehudi | Yom Yerushalayim 5783

Event Name*

First Choice

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Applicant Details

First Name*

Surname*

Email Address*

Phone Number*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

High School*

Group Number*

What do you hope to gain from this trip?

Passport Details

Please include these details exactly as shown on your passport.

Date of Birth*

DD slash MM slash YYYY

Citizenship*

Is your passport valid 6 months after the date of return to the UK?*

Yes

Passport Number*

Passport Expiry Date*

Day

Month

Year

Gender*

Male

Female

Parent/Guardian Emergency Contact

Parent/Guardian 1 First Name*

Parent/Guardian 1 Surname*

Parent/Guardian 1 Phone Number*

Parent/Guardian 1 Email Address*

Parent/Guardian 2 First Name

Parent/Guardian 2 Surname

Parent/Guardian 2 Phone Number

Parent/Guardian 2 Email Address

Emergency Contact Name in Israel*

Emergency Contact Phone Number in Israel*

Further Information

Do you have any medical conditions we need to know about? Please note we will not take responsibility should you fail to declare important information

Have the medical conditions mentioned above been stable for the last 6 months?

Yes

If no, please give more information

Please list any medication that the participant regularly takes (with the doses)

Is there any medication that the participant is allergic to?*

Yes

Does the participant have any other allergies?*

Yes

Please give details of any allergies, including allergies to medication

Please list any special dietary requirements or food intolerances

Does the participant carry an epipen?*

Yes

Does the participant carry an inhaler?*

Yes

Date of last tetanus immunisation*

Day

Month

Year

Terms and Conditions

I give permission for my child to be in photos and allow Mizrachi UK to use the photos for marketing purposes and any other purposes deemed necessary

I agree

Please see mizrachi.org.uk/photospolicy for the full policy wording.

Terms and Conditions*

I agree to Mizrachi UK Terms and Conditions

We would love to stay in touch with you and let you know about our vital services, our education work, events and fundraising. Your privacy is important to us, and we need your consent in order to communicate with you. Please select all the ways we can contact you.

Post

Phone

By providing this information I confirm that I am consenting to Mizrachi holding and processing my personal data to keep me informed about Mizrachi's services, courses, events and fundraising. Where you do not grant consent we will not be able to use your personal data; (so for example we may not be able to let you know about forthcoming services and events); except in certain limited situations, such as where required to do so by law or to protect members of the public from serious harm. You can find out more about how we use your data and how to withdraw your consent from our Privacy Notice.

Signed by: (Parent/Guardian Name)*

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