Thank you for your application to the AZYC Shnat Program (“Program”).
Before submitting this medical form, please ensure that.
This form will be used by coordinators and leaders in Israel to assist in the smooth running of the Shnat
experience. A copy will be given to all participating Organisations so that they may understand each
participant’s medical conditions.
As such, it is important that this document is filled in completely, accurately and honestly. Compiling this
document allows the AZYC and all participating Organisations to give all participants the healthiest and
most enjoyable experience possible.
If any changes take place in the Participant’s condition within the last ten days before departure, the
Participant must submit, before departure, an explanatory medical letter detailing diagnosis, prognosis,
treatment and confirmation that the Participant is fit to attend the Program. Failure to submit such a
letter shall result in expulsion of the applicant from the Program without any refund.
There have been previous instances where a medical form has not been filled in completely and
honestly, and a participant has subsequently been sent home from the Program due to that participant’s
ALL INFORMATION PROVIDED IS KEPT STRICTLY CONFIDENTIAL BETWEEN THE
Pages 4 to 12 of this form must be completed by a physician who has known the Participant for at least
12 months prior to the filling out of this form.
In addition, any participant who has been under the care of a specialist (for example, cardiologist, neurologist, psychiatrist, psychologist, social worker, etc.) must submit a written detailed report from this specialist giving complete diagnosis, prognosis, evaluation, approval for international travel and confirmation that the Participant is fit to attend the Program.
The Program can be a strenuous experience due to the intensity of the activities and the communal lifestyle that the Participant will inevitably face. As such, we kindly ask you to detail your thoughts on the suitability of the applicant living under the following conditions:
If the Participant is required to continue receiving medication while under the auspices of the Program, then the Participant must include a medical letter giving full details. Since very often medicine is not available under the same trade name as in the country of origin, the full pharmacological name of all medicines and drugs used by the Participant should be given. Please specify dosage, and distinguish clearly between regular and occasional medication and the circumstances in which the latter may be required. In any event, the Participant should bring an extra supply of the required medicine on the Program, some of which should be entrusted to the group leader.
All information is kept confidential between the participating Organisations. This medical form will be in the possession of the group leaders throughout the program in Israel.
Please feel free to contact me if you have any queries about this form or more specific details on the nature of activities usually conducted on the Program.
Kind regards, Morgan Rothschild National Chairperson, Australasian Zionist Youth Council (AZYC) Mobile: 0408 168 058 Email: [email protected]
PAGES 4 TO 12 OF THIS MEDICAL FORM TO ONLY BE COMPLETED BY THE EXAMINING PHYSICIAN
Please tick if any of the following applies to the Participant and include details where necessary. If supplied space is insufficient, please attach additional pages.
Is full strenuous activity possible? Yes / No (please circle one) Please
I have read the “Notes to the Examining Physician” on the cover of the examination form and thereafter have
examined the Participant, _______________________, whom I have known for _____ years. I have good
knowledge of the Participant and his/her medical reports, and hereby certify that the details given in the form
are complete and correct.
The results I have recorded represent, to the best of my knowledge, all of the Participant’s medical history
that has been requested. I understand that the Program organisers will rely on my report and findings. In my
opinion the Participant is physically, mentally and emotionally capable of participating in the Program.
In my opinion, ________________________ is / is not (please circle) capable of participating in the Program as outlined.
We hereby certify that:
We realise that the medical insurance provided on this program will not cover pre-existing medical
conditions. We also realise that medical coverage does not include dental treatment or any form whatsoever
All medication that the Participant takes regularly is at our own expense, and has been detailed on this form
or letters. We also give our full permission for all treatment of any nature deemed necessary by doctors in
Israel to be extended to the Participant.
306 Hawthorn Rd, Caulfield South, VIC 3162
(03) 9272 5678
2023 AZYC. All Right Reserved. Website By Omni Online