Student/Parent Medical Form and Visa Information Medical Disclosure FormName of Student(Required) First Last Student Email(Required) Student WhatsApp Number(Required)Format: (000) 000-0000Date of Birth(Required) MM slash DD slash YYYY 1. Emergency Contact in Israel Name(Required)Relationship to student(Required)Emergency Contact Phone(Required)2. Do you have any allergies or special dietary requirements (ex. vegetarian)? Please include allergies to medications.(Required) Yes No Allergies / dietary details3. Have you been diagnosed with a learning disability?(Required) Yes No If yes, please describe.4. Do you take medication for a learning disability?(Required) Yes No If yes, please describe.5. Have you ever received a diagnosis in any of the following areas: mental/emotional/mood disorders, anxiety, OCD, autism spectrum disorders, or eating disorders?(Required) Yes No If yes, please describe.6. Have you ever received psychological counseling?(Required) Yes No If yes, please describe.7. Please list any prescription medication you have taken regularly at any point in the past 3 years, and indicate which you currently still take:8. Have you ever been the subject of significant disciplinary action in school, work, or another organized setting? (ex. suspension, probation).(Required) Yes No If yes, please describe.9. Have you received all of the vaccines recommended by the Israeli Ministry of Health, listed below?(Required) Hepatitis A - Two doses Hepatitis B - Three doses Diphtheria, Tetanus, Pertussis (DTaP, TDap) - Three doses, latest one within 7 years Inactivated or Oral Poliovirus (IPV or OPV) - Three doses Measles, Mumps, Rubella (MMR) - Two doses Meningococcal ACWY - Two doses Select AllWe certify that this information is complete and accurate to the best of our knowledge. We certify that the student is physically and emotionally healthy enough to participate in the program, and that it is the student’s responsibility to let the program know if the student is unable to participate in any activity due to physical or emotional limitations.Parent Signature(Required)Student Signature(Required)Consent Form – HIPAA WaiverI give permission for such diagnostic, therapeutic or emergency operative procedure as may be necessary to evaluate and treat me / my child (name of student below).I also agree to waive my / my child’s HIPAA (Health Insurance Portability and Accountability Act of 1996) rights, Israel’s patient privacy laws, and all other applicable privacy provisions under the law, in order to allow the Maccabi Insurance Company medical providers, Israel XP at Bar Ilan University (hereafter TIDE, Inc.), and Egert & Cohen healthcare providers, contractors, professional colleagues, and relevant institutions to communicate with me, each other, healthcare providers, parents, and school administrators regarding my / my child’s medical or mental health condition/s (on a need-to-know basis), and in organizing my / my child’s health care needs, safety, and planning. This communication may be applicable via phone, email, WhatsApp, internet-based applications (including OneTapCare application), or other forms of communication.I furthermore agree to terms of service as described by TIDE, Inc. and Egert & Cohen website and/or management.More information on HIPAA and Israeli patient rights are available at:https://www.hhs.gov/ocr/privacy/hipaa/faq/authorizations/https://www.health.gov.il/English/Topics/RightsInsured/Pages/patient_rights.aspxName of student(Required)Name of parent/guardian(Required)Student Signature (HIPAA)(Required)Parent Signature (HIPAA)(Required)Student Visa InformationAnyone entering Israel with a non-Israeli passport must make sure your passport will be valid for at least 6 months after your expected departure date (if you leave on the last day of XP, that will be June 14, 2027). Please check your passport now and start the renewal process if you need to do so.Passport validity status:(Required) I checked and my expiration date is Dec 14, 2027 or later. I will start the renewal process now, or the process to get a passport if I don't have one. I will enter Israel on an Israeli passport. Passport Number(Required)Passport Expiration Date(Required) MM slash DD slash YYYY If your non-Israeli passport is valid through Dec 14, 2027, please attach a photo of it here.Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 64 MB. Pick which option applies to you:(Required) a. Neither of my parents were born in Israel and I will be 18 before October 7, 2026. b. Neither of my parents were born in Israel and I will NOT be 18 before October 7, 2026. c. One of my parents was born in Israel. d. I was born in Israel or I made aliyah at some point. Non-Israeli Citizens (a & b)Non-Israeli Citizens: If you will not be 18 before October 7, 2026, you must obtain your student visa at your local consulate before arriving in Israel. If you will be 18 or older upon arrival, you may either apply for a student visa at your local consulate, or apply online after arriving in Israel.Visa application method:(Required) I will apply for a visa at my local consulate. I will apply for a visa online after arriving in Israel. Israeli Citizens and Children of Israeli Parents (c & d)Israeli Citizens or Children of Israeli Parents: Israel requires that you obtain an Israeli passport and an exemption from the army. You are ineligible for a student visa.Israeli passport status:(Required) I will get an Israeli passport and army exemption before I come to Israel XP. I already have an Israeli passport (and an exemption, or I will get one). I already have an Israeli ID number, but still need to get a passport. If you have an Israeli ID number (teudat zehut), please enter it here.If you have an Israeli passport, please attach a photo of it here.Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 64 MB.
