Medical Form Part A – Personal and Medical Information

March of the Living 2022-2023 Application

Medical Form Part A: Medical Information

To be completed by Parent(s)/Guardian(s)

Medical Form Part A & B due by November 16th.

Physical Examination Form Upload due by January 2nd.

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Your teen is applying to participate in Miami's Leo Martin March of the Living 2022-2023 program. Miami’s March of the Living is an year long identity-building program that uses Poland and Israel as a platform to study the history of the Holocaust and examine the roots of prejudice, intolerance and hatred. Click Here for the program calendar for you to review to ensure your child can participate fully.

In order for their application to be complete, you, as the selected parent/guardian must complete the medical portion of the application. Part A & B should take you about 10 minutes to complete. We suggest using a computer and not a phone to access the form.

There are three parts of the medical paperwork:

Medical Form Part A
Medical Form Part B
Physical Examination Form Download and give to physician
Physical Examination Form Upload the completed form

Please note that it is extremely important that you provide us with complete information about your teen's medical and psychological history. This information is vital to ensure your teen's safety and wellbeing. Please take the time to complete this form accurately and thoroughly. Omissions can be serious for the individual and can affect the entire group.

All information will be kept strictly confidential by Miami's March of the Living staff and will only be referenced or shared with others to assist in ensuring the physical, psychological, and emotional wellbeing of your teen.

Please complete all fields to the best of your ability.

*Denotes a required field

Be sure to enter your teen's email address below exactly how it appears in the email you received.

GENERAL INFORMATION

Has your teen ever been away from home for an extended time period?^*

Please describe^*

Was your teen ever homesick?^*

Please describe how this homesickness was expressed and how they dealt with it?^*

Has your teen ever visited Israel?^*

How many times has your teen traveled to Israel? How old was your teen when they visited Israel and what type of trip was it?^*

Has your teen traveled outside of Florida since March 2020?^*

Has your teen traveled without you since March 2020?^*

PERSONALITY

What are your teen’s social strengths?^*

What does your teen do when they are angry, frustrated or disappointed?^*

What does your teen do when they are happy or excited?^*

What does your teen do when they are bored?^*

How does your teen deal with transitions?^*

Does your teen have any fears? How does your teen react to these fears?^*

What strategies are helpful in supporting your teen through challenging situations?^*

Does your teen demonstrate any learning, behavioral, attention, or anxiety issues? If so, please explain^*

Is there anything about you/your teen’s home situation that you would like to share with us in confidence so we can understand/be supportive of your teen?^*

SLEEPING HABITS

What time does your teen normally go to sleep at night?^*

How does your teen manage little and/or lack of sleep?^*

Does your teen wake up during the night?^*

Please explain^*

Does your teen walk in their sleep?^*

Please explain^*

Does your teen regularly talk in their sleep?^*

Please explain^*

Does your teen usually wake up in the morning on their own/with an alarm versus relying on a parent to wake them in the morning?^*

Wakes up on their own
Relies on parent to wake up

EATING HABITS

Is your teen's appetite regular?^*

Would you describe your teen as a fussy eater?^*

Does your teen currently have, or have they had a history of an eating disorder?^*

Please explain your answers to the above questions as well as any treatment or suggestions that have worked in you/your teen's past:^*

Details concerning dietary allergies or any other dietary needs or restrictions. The program is fully Kosher. If there are none, please write "none".^*

MEDICAL HISTORY AND CURRENT INFORMATION

Please check all that apply^*

Accidents/Serious Injuries
Anorexia
Arthritis
Asthma
Bronchitis
Bulimia
Cancer
Chicken Pox
Convulsions/Epilepsy
Colitis
Diabetes
Ear Infection
Eye Trouble
Fainting
Frequent Colds
Gynecological Disorders
Hay Fever
Headaches
Heart Trouble
Hepatitis
Incontinence
Jaundice
Kidney Trouble
Lactose Intolerance
Mononucleosis
Mumps
Operations
Pneumonia
Rubella
Thyroid Disorder
Tuberculosis
None
User Input

Please use this space to provide dates and/or specific information for all items checked above, including details concerning any diseases, allergies, operations and serious injuries checked above. If you did not check any items, please write "none":^*

Allergies^*

Insect Sting Allergies
Medicine Allergies
Penicillin
Dust
Food Allergies
Other Allergies
None

Please use this space to provide dates and/or specific information for all items checked above regarding allergies including severity, symptoms, treatment, etc. If allergies are severe, please identify if your teen carries their own EpiPen. If there are no allergies, please write "none":^*

Does your teen have any chronic or recurring illnesses?^*

Please list^*

We understand that teens may go on antibiotics prior to traveling with Miami's Leo Martin March of the Living. If your teen goes on antibiotics 30 days prior to our departure, I agree to let Miami's Leo Martin March of the Living staff know.^*

Yes. I agree.

Miami's Leo Martin March of the Living will make every effort to ensure that all allergy needs are met during the entire program, as well as when traveling to Poland/Israel. Despite our efforts as an Organization, the teen should still be responsible for examining everything given to them with great caution before consumption. Please take into account that allergy awareness in Poland/Israel is still not fully developed.^*

Yes, I understand.

Miami’s March of the Living is emotionally, spiritually and physically demanding. Each March participant will face a new and strenuous environment. They will be living, eating and sleeping in a communal environment. They will be expected to participate in activities which will include long bus rides, walking long distances and other strenuous activities. They will visit places such as Auschwitz, Majdanek and Treblinka, where they will be emotionally affected. Do you understand these requirements?^*

Yes, we understand

Is your teen able to meet these requirements?^*

Admin use only (do not edit)

Registrant(Teen) Email Address^*

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