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FORM - Accidents and Illness
Name of the young person who is the subject of this form
(Required)
Name of medic
(Required)
Email
(Required)
Date
(Required)
MM slash DD slash YYYY
Machane
(Required)
Mapoeh
Gimmel
H-Course
Year Group or Age of young person
What happened? Please include timings, any information about cause, and any action taken.
(Required)
Did they go to a hospital, doctor's surgery, walk-in centre, or anywhere of a similar nature?
(Required)
Yes
No
What is the name of the place they went to, and what is its nature (e.g. hospital)?
(Required)
Name of the escort
(Required)
Please specify what time (and date) they left machane, what time (and date) they returned, and who drove them (each way).
(Required)
Medical Diagnosis
(Required)
Please include medication prescribed and prescription pick-up details, if relevant.
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Camps
Svivot
Hachshara
Israel Machane
Otzar Torah MiTzion
Aliyah
Contact
Bachad
DONATE
LEGACY
facebook
youtube
instagram
phone
email
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