"Tour and Care" Students Health Policy Sign Up

Darchei Bina 2023

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Personal Details

First Name *

Last Name *

Gender *

Male

Female

Name of Yeshiva/Sem/Program *

Date of Birth *

Age *

Passport Number *

Country of Passport *

Citizenship *

Date of Entry to Israel *

Purpose of Visit *

You may change the default program dates below, but please note that changes to the default program dates may incur additional charges on your policy.

Start Coverage in Israel (dd/mm/yyyy) *

End Coverage in Israel (dd/mm/yyyy) *

Address where you are staying in Israel:

Street *

House no. *

Apartment no.

City *

ZIP

Mobile Phone Number in Israel *

Email * Email for personal notifications and mailings.

Phone Number at Home *

Provider Selection: *

Harel Chai

"Tour and Care" Students Health Policy Sign Up

Darchei Bina 2023

Personal Details

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