Summer Machane 5778 Junior Tafkid Form

Email address*
Name*
First Last
Gender*
- Male
- Female
Shevet (or if not known year group)*
Mobile Number*
Address*
Street Address ZIP / Postal Code Country
Do you have a current CRB/DBS?*
- Yes
- No
If yes, what is your current valid DBS number?
Do you have Mas Chaver 5778? (you must have Mas Chaver 5778 to take Summer Machane)*
- Yes
- No
If yes, what's your number? (if no you will be invoiced)
Give a summary of your involvement with Bnei Akiva to date*
What are you doing this year?*
Why do you want to be involved in Bnei Akiva Machane?*
Which Tafkid would be your first choice?*
Which Tafkid would be your second choice?*
Which Tafkid would be your third choice?*

Emergency Contact Details
Please provide the contact information of someone who will be available for the entire duration of Machane
Name*
First Last
Relation to you*
Emergency Contact Phone Number*

References
Are you a first time madrich/a?*
- Yes
- No
Reference 1 Name*
First Last
Reference 1 Position (must be someone who has held a senior position in Bnei Akiva)*
Reference 1 Phone*
Reference 1 Email*
Reference 2 Name*
First Last
Reference 2 Position*
Reference 2 Phone*
Reference 2 Email*

Insurance Details/Disclaimers
Do you have travel insurance?*
- Yes
- No
Would you like to take out insurance under the Bnei Akiva policy? (If yes, we will be in touch for payment)*
- Yes
- No
By selecting Yes you agree that Bnei Akiva has permission to take photos of you that may be used publicly by Bnei Akiva E.g. advertising*
- Yes
- No
I can confirm that I will be available between the dates 25th July - 14th August 2018 and I will attend Machane for its entire duration*
- Yes
- No
Please give details*
Terms and Conditions
1) Membership of Bnei Akiva is available only to persons of the Jewish Religion according to the rulings of the Office of the Chief Rabbi.
2) Membership lasts for 1 Jewish year only Rosh Hashanah to Rosh Hashanah and must be renewed accordingly.
3) The supply of incorrect information may at the discretion of Bnei Akiva render membership invalid.
4) Bnei Akiva reserves the rights at its discretion to revoke membership for any reason it sees fit.
I hereby declare that to the best of my knowledge, this form is accurate and complete . I understand that Bnei Akiva will not be responsible for any medical condition either physical or emotional, resulting from my failure to disclose relevant information prior to my arrival at camp.
I understand that pre-existing conditions that have not been declared may result in me being returned home immediately at my expense and no refund given.
I agree with the terms and conditions*
- Agree

Medical Details