Medical Information Part B – Email – Miami March of the Living

March of the Living 2024-2025 Application

Medical Form Part B: Personal and Medical Information

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

Physical Examination Form Upload due by

October 1, 2024.

Medical Form Part B & C due by

October 1, 2024.

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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 well-being. 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 well-being 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.

Registrant(Teen) Email Address^*

I acknowledge that I will do my best to attend the Parent Orientation on Wednesday, February 26, 2025, at 6:30 pm at CAJE offices, 4200 Biscayne Boulevard^*

I would be interested in attending a gathering for parents at someone's home to hear from a Holocaust Survivor in mid-March 2025^*

Would you be interested in hosting this program?^*

Due to enhanced safety protocols, increased travel expenses, and an enriched educational experience, we anticipate the tuition to range between $7,995 and $9,995. If the program is limited to travel to Poland only, the range will be $5,795 to $6,995. Additionally, travel and medical insurance must be purchased independently of the tuition fee. The exact costs and cancellation policy will be finalized by October 2024, with all payments due between November 2024 and February 2025^*

Yes, I acknowledge

Participation in the pre-March educational sessions are mandatory so please check your personal calendars and mark the dates accordingly. CLICK HERE TO REVIEW THE MOTL CALENDAR

I understand that failure to comply with the payment schedule, the timely submission of necessary paperwork/uploads and/or not participating fully in all preparatory sessions could jeopardize the teen participant’s spot on the March of the Living Program. Please agree below to confirm that both parents and teens understand the requirements for the program^*

Yes, I acknowledge

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?^*

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?^*

If your teen gets in trouble at school or at a youth group prior to traveling, they may not be able to participate in the program and all associated costs will be applied.^*

I understand

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?^*

What are the primary foods that they would eat?^*

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

Has your teen ever tested positive for Covid-19?^*

What were their symptoms?^*

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 describe^*

Vaccinations-Enter NA if your child has not received the vaccination.

DPT Series^*

Polio^*

Hepatitis A^*

Varicella^*

Flu Vaccine^*

Tetanus Booster^*

MMR^*

Hepatitis B^*

PPD^*

PPD Status^*

Positive
Negative
NA

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
No, I do not 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
No, I do not understand

Miami’s Leo Martin 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
No, we do not understand

Is your teen able to meet these requirements?^*

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