Please note, you will need the applicant's passport (if you already have one) and medical information (including physician/clinician contact information) to complete the application form.
Please note: It is Keshet Policy for a staff member to accompany participants in the examination room while being examined by a doctor or other health professional unless asked by the patient to leave.
Terms and Conditions: By entering my name and date below, I affirm that the above health history is correct and accurately reflects the health status of the participant to whom it pertains. The applicant has permission to participate in all program activities except as noted by me and/or an examining physician. I give permission to the physician selected by Keshet to order X-rays, routine tests, and treatment related to the health of the applicant for both routine health care and emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the applicant. I understand the information on this form will be shared on a 'need to know' basis with program staff. I give permission to make copies of this form. In addition, Keshet has permission to obtain a copy of the applicant's health record from providers who treat him/her and those providers may talk with the program staff about the applicant's health status.
Please read the following carefully: The Code of Conduct is designed to ensure the safety and well-being of all participants on the Get Connected Summer Trip to Israel. Please read it carefully and indicate your agreement to all of the provisions where indicated. (You will not be permitted to depart with the Get Connected group unless the Code of Conduct has been received, reviewed, and approved by the Get Connected staff.)
Health and Safety - between parent/guardian, program participant, and Get Connected
The following includes what we, the Get Connected organizers and staff, believe to be the most appropriate policies to ensure the health and safety of each individual participating in our programs. We expect and understand that, as with all recreation/travel programs, young people may not always exercise the best judgement in every situation resulting in consequences of those choices/actions. However, because the Get Connected program is one of international travel and all that implies, there are mandatory prescribed limits of acceptable personal behavior. This behavior code will be strictly enforced and expulsion from the program (prior to departure or during the trip itself) may occur at the sole discretion of the group's chaperones and Get Connected staff. Should a participant be expelled from the program, understand that there is absolutely no refund of any monies paid any expenses incurred in the process of separating the participant from the program's activities are the sole responsibility of the parent/guardian. Disciplinary action is not arbitrary and attempts are made to be progressive in our approach. However, specific activities such as, but not limited to, the possession or use of drugs and/or alcohol; unexcused absences from the program activities; violation of curfew; acts/behaviors posing an implied or actual threat of harm to other participants, chaperones, or others; destruction of property; theft; and interpersonal sexual activities or inappropriate sexual behaviors may warrant expulsion from the program.
The following is a list of expectations for all participants in the 2018 Get Connected Program:
The following rules concern the participant's responsibilities to the Get Connected group and chaperones/leaders:
The following activities are strictly prohibited:
I have read the above regulations and responsibilities and agree to abide by them. I understand that any violations of the above Code of Conduct will be addressed by the group leaders/chaperones and could result in my being sent home (with the expenses incurred being the sole responsibility of me and my parent(s)/guardian(s). I understand that the decision regarding my expulsion from the program would be at the sole discretion of the group leaders, chaperones, and Get Connected staff.
As the parent/legal guardian of the above-named applicant, I request that in my absence, the above-named Get Connected participant be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, staff, duly liensed or other such licensed technicians or nurses to perform any diagnostic procedures, treatment procedures, operative procedures, and X-ray treatment of the above-named minor. I have not been given any guarantee as to the results of such examination or treatment. I authorize the hospital amd/or medical staff to disposed of any speciment or tissue taken from the above-named participant.
I have read and agree to the conditions listed in the application and I hereby agree to them.
In consideration for me and/or my family member(s) being permitted to participate in the programs and activities of the Get Connected program, I hereby release, waive, forever discharge, and covenant not to sue Get Connected, it's governing board, officers, agents, empoloyees, chaperones, and volunteers ("releasees") from and against any and all liability for an harm, injury, damage, claims, demands, actions, causes of action, cost and expenses of any nature which I and/or my family member(s) may have or which hereafter accrue, arising out of or related to any loss, damage, or injury that may be sustained by me and/or my family member(s) or by any property belonging to me and/or my family member(s), whether caused by negligence or carelessness of the releasees or otherwise while I and/or my family member(s) are participating in any activities or any adjunct to such activities of the Get Connected program.
It is out express intent that this agreement shall bind te members of my family (and spounse if married). I and/or my family member(s) agree to save and hold harmless, indemnify, and defend the releasees from any claims arising out of our participation in these activities.
In witness whereof, the parties hereto have signed this agreement by entering our names and the date of this agreement.
That's all for the basic application. Please click Submit to complete the application and to receive information regarding the next steps.