Israeli Needs Form

MailChimp Tag / Form Name
Memo
Notes to internal Federation professionals
Name*

First NameLast Name
Email*

Confirmation EmailConfirm email address
Date of Birth

MonthDayYear
I am filling this out for...*

Myself / my familyOther
Needs

Please provide insight into the specific needs that you may have.
Does anyone in the household need mental health support? (check all that apply)

Preschool-aged childrenSchool-aged childrenTeensYoung adultsAdultsSeniorsOther
How many preschool-aged children need mental health support?*
How many school-aged children need mental health support?*
How many teens need mental health support?*
How many young adults need mental health support?*
How many adults need mental health support?*
How many seniors need mental health support?*
Is housing required?*

YesNo
How many individuals are in the household?*
What particular housing accommodations are needed?*

Walking distance to synagogueClose proximity to schoolsHandicap accessNo accommodations neededOther
Our partner schools are accepting Israeli children and providing age-appropriate learning during this time. This includes our four community day schools, as well as numerous Early Childhood Centers and religious schools. If you are in need of programming and/or education for your child, please select the options below that best fit your need(s):

Caregiver and mePreschoolPrograms for young childrenGrade schoolMiddle schoolHigh schoolJewish day schoolPublic school
Please let us know what specific medical care referral is needed? (Pediatrician, general practitioner, prescriptions, etc.).
Is medical insurance also needed?*

YesNoI don't know
Are household items, goods, or clothing needed? Please indicate ages, sizes, gender, etc.
Is legal assistance needed?*

YesNoI don't know
Is employment assistance needed?*

YesNoI don't know
Looking to connect with other Israelis in the community?*

YesNoI don't know
Have you sought assistance from other agencies?*

YesNoI don't know
Please explain
Please explain any other needs not covered above.
paymentData
Thank you for sharing. A Federation professional will reach out to discuss your request. Please note, we cannot guarantee but will do our best to address your needs.
Total Ticket Cost (hidden)
Gift Amount
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Gift Amount to send check
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Cc fee
TOTAL = Subtotal Amount to charge + fee
Should be Empty: