Please complete this form so that we can send it to your madrichim so they know a bit about you before they arrive in Israel:

Personal Information:

First Name:

Last Name:

Sex:

Age:

School:

Date of Birth:

Home address:

Home town:

Home postcode:

Telephone number:

Home Fax (if app.):

Mobile/pager (if app.):

Email (if app.):

What experience have you previously had with Mifgashim?

Have you visited the UK before (if so please specify where and when)?

What subjects do you study in school?

Have you got any idea what you might want to do in later life?

What activities do you have outside school? (ie hobbies):

What is your favourite place in Israel:

What leadership experience have you had before?

What are you looking forward to most about Israel tour:

Why do you think you have been invited to join Aj6 Israel tour:

Please describe yourself in a sentence:

Medical Information: (this information will be kept confidential)

Please list any allergies which you may have:

Are you on any current medication (if so please specify which):

Do you have any re-occuring illnesses which we should know about?

Have you ever suffered from any mental conditions (ie depression)?

Is there anything else about your medical history which your madrichim should be aware of?

Signed _____________________________
Date _________________

Elul 5760 - September 2000