Application for: Israel Service Corps - Short Term Volunteering Application Complete the following application and click submit below. Note that your personal information will not be shared with anyone other than the program admission staff. * Obligatory Fields * First Name:   Middle Name: * Last Name: * Gender: Please Select Male Female * Date of Birth: Day 01020304050607080910111213141516171819202122232425262728293031    Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember    Year 19501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990 * Present Citizenship:   Passport Number: * Religion: * Mother's Religion: * Father's Religion: Current Contact Information * Street Address: * City: * State: * Postal (zip) Code: * Country: * Home Phone Number:   Work Phone Number:   Cell Phone Number: * Email Address: Permanent Address (if different than above) Street Address: City: State: Postal (zip) Code: Country: Telephone No: Emergency Contact Information: * Contact's Name: * Street Address: * City: * State: * Country: * Telephone No: * Relationship: Education * Highest Level Completed: * Institution(s): * Major:    Minor: * Certificate / Degree: Language Skills: * Hebrew Reading: Please Select None Fair Fluent * Hebrew Writing: Please Select None Fair Fluent * Hebrew Speaking: Please Select None Fair Fluent * English Reading: Please Select None Fair Fluent * English Writing: Please Select None Fair Fluent * English Speaking: Please Select None Fair Fluent Other Language: * Other Language Reading: Please Select None Fair Fluent * Other Language Writing: Please Select None Fair Fluent * Other Language Speaking: Please Select None Fair Fluent Logistics Related Questions: * When are you looking to come? * How long are you planning to stay in Israel? * How long are you planning to volunteer in Israel? Please Select Less than 2 weeks 1-3 weeks 3-6 weeks More than 6 weeks * What geographical area do you prefer to be located in? Please Select north (Haifa & Galilee) Tel Aviv (and surrounding areas) Jerusalem (and surrounding areas) Beer Sheva (and surrounding areas) Eilat (and surrounding areas) * What will be your accommodations? Please Select I have my own accommodations I need assistance with arranging a hotel * Are you interested in us assisting you in arranging private tours during your stay? Yes       No Volunteer Placement Questions: * What age group are you looking to volunteer with? Please Select Elementary school and younger Middle school High school Adults Senior citizens other * How many hours per day are you looking to volunteer? (ex: morning, afternoon, all day) * Please check which areas interest you. Check all that apply. Welfare     Education After school care     Tutoring English Environment     Summer camps Other: * Do you have any certifications/licenses that may aid in your volunteer placement? Previous Israel Experience: Birthright Israel Year: Select 1999 2000 2001 2002 2003 2004 2005 2006 If yes, which organizer Other Program: Year: Select 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 When were you last in Israel? General Questions: What are your expectations as a participant in the Israel Service Corps - Short Term Volunteering program? * Related Experience: Please out line all volunteer experience in your fields of interest , please include work in both individual and group settings. For better matching your needs, please provide concrete examples of what you can offer ISC and the hosting community based on your values, talents and passions.: Have you ever been arrested, charged or convicted of a felony violation? Yes     No Have you ever been charged with neglect, abuse, or assult? Yes     No If Yes to either of the above two questions, please write a brief letter which states your name, the specific charge, an explanation including the date and place and outline the penalty/punishment. Email this letter to volunteer@israelservicecorps.com. Information will not be shared with anyone other than the program admission staff. Where and from whom did you first hear about the Israel Service Corps - Short Term Volunteering program? Please specify. If you were referred by someone, please provide their name and how they are connected to Oranim/Israel Service Corps. Medical Information: * Are you healthy? YES     NO * Are you currently under the treatment of any medical or mental health professional? YES     NO * Have you ever been treated for any psychological problems? YES     NO * Are you currently taking any prescription medications? YES     NO * Have you ever been diagnosed with cancer, disorders of the central nervous system, TB, epilepsy, asthma, heart disease, diabetes or any other disease(s)? YES     NO * Have you ever been admitted to a hospital? YES     NO * Have you been diagnosed with any learning disabilities (including dyslexia, ADD, ADHD, etc), hearing or speech impediments which may infringe on your ability to function in a new environment and to successfully learn a new language? YES     NO * Do you suffer from any condition not covered above that may impede your full and successful participation in the Israel Service Corps - Short Term Volunteering program? YES     NO If yes to any of the above please give details below, including any medications that you will be taking while in Israel. In addition, please have your personal physician write a letter outlining your medical condition(s) and your ability to fully participate in this program. By checking this box, I certify that all the information I've provided in this application is true. Should Oranim/Israel Service Corps find out otherwise, your application will not be considered.