Yehudi | Year 12 Application & Shabbaton 5784

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Year 12 Application & Shabbaton Form 5784

Year 12 Shabbatonim will be held in Brighton on Friday 27 October (Girls) and Lincolnsfield on Friday 13 October (Boys). The registration fee will cover the full cost of this mandatory Shabbaton. More details will be sent nearer the time. If you would like to apply for financial assistance for the cost of this programme and Shabbaton (£10), please email lelia@mizrachi.org with the subject line "Yehudi FA".

SECTION 1: APPLICANT DETAILS

First Name(Required)

Last Name(Required)

Gender(Required)

Male

Female

Is this your first time on a residential trip?

Yes

No

Please provide a reference (this can be a teacher, Madrich, etc)

Reference Name

Reference Email

Date of Birth(Required)

Day
Month
Year

School year starting in September(Required)

Year 12

Please list two friends who you would like to share a room with - this is not a guarantee, but we will try

Email(Required)
Enter Email Confirm Email

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

Mobile number (with WhatsApp)(Required)

School(Required)

Synagogue(Required)

Are you part of a youth movement? If so, which?(Required)

Dietary Requirements?(Required)

Yes

No

Please list your dietary requirements

Please upload a recent photo(Required)
Accepted file types: jpg, jpeg, png, gif.

Section 2: PARENT/GUARDIAN(S)
Parent/Guardian 1
Title(Required)
First name(Required)

Last Name(Required)

Mobile phone(Required)
Home phone
Email(Required)

Synagogue(Required)

Address(Required)
Same as previous

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

Parent/Guardian 2
Title
First name

Last Name

Mobile phone
Home phone
Email

Synagogue

Address
Same as previous

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

Section 3: YEHUDI QUESTIONNAIRE
Why do you want to join the Yehudi programme?(Required)
(Max. 500 words)
What makes a good leader?(Required)
(Max. 500 words)
Please give us an example of a role model you have and why.(Required)
(Max. 500 words)
Have you had any previous leadership experience?(Required)
(Max. 500 words)
If you had 10 minutes to run a session with younger children, what would you do?(Required)
(Max. 500 words)
Discuss in 500 words or less: It is important to spend a gap-year in Israel.(Required)
(Max. 500 words)

SECTION 4: MEDICAL AND WELFARE INFORMATION
Doctor's name(Required)

Name of practice(Required)

Practice Address(Required)

Phone(Required)
Please inform sharon@mizrachi.org of any changes
Do you take regular medication? If so, please provide deails.(Required)

Do you have any allergies?(Required)

Do you suffer from any of the following: asthma, hyperventilation, panic attacks, skin disorder, diabetes, Hay Fever(Required)

Yes

No
Do you carry an epi pen?(Required)

Yes

No
Is there anything else (family background, medical) that Yehudi Welfare should be aware of?(Required)

Yes

No
Have you ever been diagnosed with any condition which Yehudi Welfare should be made aware of? e.g., Dyslexia, ADHD, Hyperactivity, Hypermobility, eating disorder, self-harm, autism spectrum, Asperger’s syndrome, anxiety, OCD, any mental health related disorder? If yes, please give details below.(Required)

Yes

No
If you answered 'Yes' to any of the above questions, please provide details
Have you ever been excluded from school or a youth movement or ever been sent home early from a residential trip?(Required)

Yes

No

SECTION 6: T&Cs
I agree that any violation of the T&Cs will result in my immediate removal from the programme and I explicitly agree to cover any associated costs with doing so, including, but not limited to, a return trip home or repaying subsidies.(Required)

I Agree

I Disagree
I agree to only bring medication declared above on the trip.(Required)

I Agree

I Disagree
I agree to the T&Cs and cancellation policy found here: yehudi.co.uk/t-cs(Required)

I Agree

I Disagree
I consent for myself and my parent(s)/guardian(s) to be contacted by Yehudi and Mizrachi UK for matters relating to the programme, Mizrachi UK programming, fundraising and any other relevant reasons, as deemed fit. All data wil be held in accordance with GDPR. Email daniel.sacks@mizrachi.org with the subject line "GDPR Request" for any queries or to remove your information.(Required)

I Agree

I Disagree
I hereby certify the above information is correct and confirm my answers are honest(Required)

SECTION 7: PAYMENT
Would you like to purchase a YeHoodie? These are priced at £20
If yes, please select your size
The Shabbaton is mandatory and is at the cost of £10
Total

Credit Card(Required)
Card Details
Cardholder Name
Name
This field is for validation purposes and should be left unchanged.

Year 12 Application & Shabbaton Form 5784

SECTION 1: APPLICANT DETAILS

Section 2: PARENT/GUARDIAN(S)

Section 3: YEHUDI QUESTIONNAIRE

SECTION 4: MEDICAL AND WELFARE INFORMATION

SECTION 6: T&Cs

SECTION 7: PAYMENT

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