Application: New York Open Service Trip

Personal Information
Name *
Birthdate (mm/dd/year) *
Permanent Address *
City *
State *
Phone (Home)
Phone (Work)
Phone (Cell)
Email Address *
College/University *
Year in School *

Emergency Contact Information
First Emergency Contact
Name *
Relationship *
Phone (Day) *
Phone (Evening) *
Phone (Cell)
Email Address *
Second Emergency Contact
Name
Relationship
Phone (Day)
Phone (Evening)
Phone (Cell)
Email Address

If you have any questions regarding this application, or if you would prefer to speak to someone directly, please contact Jamie Beran at 212.213.2113 x35 or via email at jberan@jewishjustice.org.

Medical Information
The information provided here will help the staff of the Jewish Funds for Justice to provide or obtain appropriate medical care for you. This information will be kept strictly confidential, and will be viewed only by a minimum of JFSJ staff members and, if necessary, by health care providers charged with caring for you on site. If there are any changes to the information provided here between now and the program's start date, please bring these to attention of the Jewish Funds for Justice staff.
No applicant who would be otherwise qualified for the program will be turned away on the basis of his/her past or present medical or emotional care. By providing this information, you help us to provide the best care for you.

Physician Information
Name of primary care physician: *
Address: *
Phone Number: *

Allergies
(Please list any food allergies and note the manifestation and management of these allergies. For instance: Does the allergy cause an anaphylactic reaction? Stomach ache? Hives? Do you carry an epi-pen? Do you take Lactaid before dairy meals?)
Peanuts: *	Yes No
....
Other Nuts: *	Yes No
....
Dairy: *	Yes No
....
Eggs: *	Yes No
....
Other: *	Yes No
....
(Please list any other allergies and note the manifestation and management of these allergies.)
Bee Stings: *	Yes No
....
Other Insects: *	Yes No
....
Hay Fever: *	Yes No
....
Animals: *	Yes No
....
Dust: *	Yes No
....
Medication: *	Yes No
....
Other: *	Yes No
....

Food Preferences
Do you eat the following foods: *	Fish Eggs Dairy Meat
Do you keep kosher? *	Yes No
Do you eat vegetarian food prepared in a kitchen that is not under kosher certification? *	Yes No
(Please note that JFSJ will accommodate all kashrut needs.)

Medications
Please list ALL medications (including over-the-counter or non-prescription drugs) taken on a regular basis. Please bring enough medication to last the length of the program, and make sure that you pack this medication in your carry-on bag. Keep all medication in the original packaging bottle that identifies the prescribing physician (if prescription), the name of the medication, dosage, and frequency of administration.

Please check one: *	I take no medications on a routine basis. I take medications as listed below.
Include all medication information, including dosage and times when you take your doses.

This program will involve physical work and potentially other physical activities in hot and/or humid conditions. Please explain any restrictions to activity:

If you have any questions regarding this application, or if you would prefer to speak to someone directly, please contact Jamie Beran at 212.213.2113 x35 or via email at jberan@jewishjustice.org.

General Questions
Explain "yes" answers below. Please answer all questions.

1. Had a recent injury, illness or infectious disease? *	Yes No
2. Have a chronic or recurring illness/condition? *	Yes No
3. Ever been hospitalized? *	Yes No
4. Ever had surgery? *	Yes No
5. Have frequent headaches? *	Yes No
6. Ever had a head injury? *	Yes No
7. Ever been knocked unconscious? *	Yes No
8. Wear glasses, contacts, or protective eyewear? *	Yes No
9. Ever had frequent ear infections? *	Yes No
10. Ever pass out during or after exercise? *	Yes No
11. Ever felt dizzy during or after exercise? *	Yes No
12. Ever had seizures or convulsions? *	Yes No
13. Ever had chest pain during or after exercise? *	Yes No
14. Ever had abnormally low or high blood pressure? *	Yes No
15. Ever been diagnosed with a heart murmur? *	Yes No
16. Ever had back problems? *	Yes No
17. Ever had epilepsy? *	Yes No
18. Ever had treatment for drug/alcohol abuse? *	Yes No
19. Have a history of smoking? *	Yes No
20. Ever had problems with joints (e.g. knees, ankles)? *	Yes No
21. Have any skin problems (e.g. itching, rash, acne)? *	Yes No
22. Have diabetes? (Date of onset?) *	Yes No
23. Have asthma? (Induced by what? Date of onset? *	Yes No
24. Had mononucleosis in the past 12 months? *	Yes No
25. Had problems with diarrhea/constipation? *	Yes No
26. Have problems with sleepwalking? *	Yes No
27. Have problems with insomnia? *	Yes No
28. Ever had an eating disorder? *	Yes No
29. Ever been treated by a psychologist/psychiatrist? *	Yes No
30. Ever been diagnosed with ADD/ADHD? *	Yes No
Explain all yes answers:

Insert your name below as confirmation that all medical information is correct and complete to the best of your knowledge, and the person herein described will and is able to engage in all aspects of the Jewish Funds for Justice program activities except as noted.
Signature: *
Date:

If you have any questions regarding this application, or if you would prefer to speak to someone directly, please contact Jamie Beran at 212.213.2113 x35 or via email at jberan@jewishjustice.org.

Personal Statement
Please respond to each of the following three questions. All statements are required.

1. Why do you wish to participate in this program with Jewish Funds for Justice? What do you hope to gain from it? *

If you have any questions regarding this application, or if you would prefer to speak to someone directly, please contact Jamie Beran at 212.213.2113 x35 or via email at jberan@jewishjustice.org.

Personal Statement
Please respond to each of the following three questions. All statements are required.

2. In what ways does participating in the program reflect your Jewish identity or your social justice awareness? *

If you have any questions regarding this application, or if you would prefer to speak to someone directly, please contact Jamie Beran at 212.213.2113 x35 or via email at jberan@jewishjustice.org.

Personal Statement
Please respond to each of the following three questions. All statements are required.

3. Following the program, we ask that each participant speak, teach or share about his/her experiences to his/her home community. How do you envision fulfilling this responsibility? *

If you have any questions regarding this application, or if you would prefer to speak to someone directly, please contact Jamie Beran at 212.213.2113 x35 or via email at jberan@jewishjustice.org.

Student Info
Finally, please answer the following questions. You will then be done with this application.

Please list the campus groups with which you are involved, and note any leadership positions you hold in these groups.
Please list any honors or awards you have received.
Please describe any previous service, advocacy, organizing, or other social change work with which you have been involved.
Does your family currently belong to a synagogue? *	Yes No
If yes, which one?
If no, did you grow up in a synagogue?	Yes No
If yes, which one?
How would you describe your current Jewish affiliation, interests, and practices? We ask this question in order to create a group made up of Jews of a wide range of backgrounds and practice. *

Thank you. This application is now complete. Please hit the submit button to send it to JFSJ.