Health Declartion Minor
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This document is a health declaration form for minor children applying for Aliyah (immigration to Israel) through the Jewish Agency. It collects personal and medical information about the child's health, including any illnesses, disabilities, medications, mental health issues, or addictions. The parents must declare that the information is true and acknowledge they may need to provide additional medical documents from a doctor to support the application. The Aliyah office section notes whether any follow up medical documents or exams are required.
Health Declartion Minor
- 1. CONFIDENTAL HEALTH DECLARATION- For minor children (under 18) This document is to be filled out by an Aliyah candidate requesting an Aliyah visa to Israel according to the Law of Return, through the Aliyah Office of the Jewish Agency Confidential A. Personal information on the minor: Last name Male Female First name Date of birth ____ /_____ / ____ day month year Approximate date of Aliyah _________ Making Aliyah with parents? Yes No If not, indicate who in Israel is responsible for the minor: Name: Address: Telephone: B. Information on candidate’s medical condition: 1. Is the child in good physical health and is s/he capable of fulfilling daily tasks independently? Yes No If not, please specify: 2. At the time of the request for Aliyah is the child: Attending regular/special school – in what grade? If the child attends special school or is in a special class, please specify: The child is working 3. Has the child suffered in the past, or is s/he currently suffering, from any of the following illnesses: (please check all that apply) Epilepsy Heart disease Diabetes Asthma Cancer HIV Kidney failure Tuberculosis HIV carrier 1
- 2. If you answered “Yes”, please indicate the following: When did s/he contract this illness? When s/he was last treated for these illness/es? 4. Is the child taking any medications: Yes No If so, please indicate: 1. Name of medication Purpose Daily dosage 2. Name of medication Purpose Daily dosage 3. Name of medication Purpose Daily dosage 5. If the child suffers from any disability, please indicate: Type of disability Reasons and start of disability Are there functional restrictions If your child requires ongoing medical treatment for this disability, please note the type of treatment s/he requires 6. Is your child currently suffering, or has s/he suffered in the past, from any mental illness? Yes No If so, please specify: Name of illness: Date of last doctor’s treatment for this illness If s/he was hospitalized, date of latest hospitalization 7. Has your child taken in the past, or is s/he currently taking, either occasionally or on a regular basis: – Addictive medications Yes No –Illegal drugs (of any kind) Yes No – Alcohol addiction Yes No If so, indicate: Name of medication/drug When did s/he last take it 8. Can your child endure the flight to Israel Yes No If necessary, please consult with your family physician. 2
- 3. C. Parents’ Declaration: I hereby declare that the details provided above are correct and was given with the knowledge that they will serve as a basis for considering our child’s request for Aliyah to Israel and as a basis for information and disposition in this regard. Furthermore, I am aware that this statement does not absolve me from the need to produce medical documents, from our family physician or medical institution, as requested by the Aliyah Ministry. Father’s name and signature Mother’s name and signature Date: In the event that the child makes Aliyah with only one parent, that parent shall sign the himself/herself and prove that s/he has sole custody of the child, or submit to the Shaliach the other parent’s authorization for the child’s Aliyah. FOR USE BY THE ALIYAH OFFICE The candidate has been asked to produce additional medical documents Yes No Details of documents requested Documents are attached Yes No The candidate has been asked to undergo a medical examination Yes No Findings of the examination Name of Aliyah Shaliach Date 3