Name *
Date of Aliyah *
T.Z. or Passport# *
Phone *
Do you have any difficulty standing for lengthy times or walk w cane, walker, or crutches? * Yes No
Do you need to sit in a special place on the bus or need assistance boarding/deboarding from the bus? * Yes No
Do you have special health concerns that could restrict you from long walks, climbing stairs, hills, etc? * Yes No
Do you have shortness of breath when walking on flat surfaces or on inclines? * Yes No
Have you fallen within the past 6 months? * Yes No
Notes:
Email *
Israeli Cell Phone
Email
Password
