Visitor Health Form: Village of Peace Dimona

Personal Information

Hebrew: פרטים אישיים

First Name / שם פרטי *

Last Name / שם משפחה *

Date of Birth / תאריך לידה *

Gender *

MaleFemalePrefer not to say

Nationality *

Passport / ID Number *

Required for community records. Treated as strictly confidential.

Email *

WhatsApp / Phone *

Emergency Contact

Name *

Relationship

Phone *

Health & Wellness Disclosure

The Village of Peace practices a fully plant-based, whole-food lifestyle. This information helps our Ministry of Health ensure a safe and joyful visit.

Current Dietary Lifestyle *Vegan / fully plant-basedVegetarianPescatarianOmnivoreOther

Food Allergies or SensitivitiesNoneTree nutsPeanutsGluten / WheatSoySesameOther

Current Medical Conditions

Kept strictly confidential, used only to ensure your safety.

NoneDiabetesHeart conditionHypertensionRespiratory conditionMobility limitationsPregnancyAutoimmune conditionOther

Current Medications

Physical Mobility Level *Fully mobileSome limitations - can walk with rest periodsRequire wheelchair or mobility assistanceOther

Special Accommodations Needed

Visit Details & Consent

Purpose of Visit *Guided community tourWellness / healing programVegan cuisine experienceCultural and heritage immersionSpiritual practice / studyEducational researchJournalism / mediaBusiness meetingPersonal / family visitOther

Expected Duration *Day visit (few hours)Full day2-3 daysExtended stay (1 week+)

How Did You Hear About Us?

Health Disclosure Consent

I voluntarily disclose the health information provided in this form to the Village of Peace Dimona Ministry of Health. I understand that this information will be held in strict confidence and used solely to support my health and safety during my visit. I acknowledge that the Village of Peace practices a fully plant-based lifestyle, and I consent to participating in meals and activities consistent with this practice during my stay.

I have read and I agree to the Health Disclosure Consent above. *

Photography Consent *Yes - I consent to being photographed/recordedNo - I do not consent

Your data is encrypted and stored securely. Access restricted to Ministry of Health staff only.