Please fill out form for the CTeen NY Shabbaton Teen Applicant First Name Last Name Gender Male Female School Grade Address City Zip Code Email Home Phone Cell D.O.B. Allergies Parent Info Father Name Mothers name Fathers Cell Mothers Cell Fathers Email Mothers Email Comments / Questions If you have any questions: Call us at 561-998-5391. STEP 2: CODE OF CONDUCT ► PLEASE READ AND SIGN THIS CODE OF CONDUCT No smoking is allowed. There is to be no possession or use of any narcotics, marijuana, other illegal drugs or prescription drugs not specifically prescribed for the user. There will be no possession or consumption of any alcoholic beverages. I will not shoplift or engage in any other type of illegal behavior. Any participant caught in possession of/or using alcohol or illegal drugs, will immediately be sent home at his/her parent’s expense. Participants are expected to maintain proper decorum and attitude during the entire program. Disruptive behavior (including, among other things, inappropriate sexual innuendo) will not be tolerated in any way shape or form. Your parents will be responsible to pay for any damage you may cause. No participant may leave the facility except at those times specified by the schedule. Each participant is expected to conduct him/herself appropriately as a Jew (including through the observance of Kashrut), in accordance with applicable standards of the trip organizers. The Organizers its Directors, Staff & Chaperones, reserves the right to enforce all and other rules relating to the integrity and/or the health, safety or welfare of it’s participants. I have read these rules and understand them fully. I certify that I will adhere to this Code and will conduct myself in a manner reflecting credit upon my peers, my congregation, community and myself. I understand that any violation of this code of conduct may result in my being sent home at my parents' expense. INITIALS OF PARTCIPANT I, the parent/guardian of, a minor, who will be participating in the NYC Shabbaton 2020, do hereby certify that I have read the Code of Conduct set forth above. I do hereby agree that if my child who has signed the above Rules of Conduct fails to adhere to the Code, then in such event those persons in charge of the program may send my child home at my expense. INITIALS OF PARENT/GUARDIAN Date STEP 3: DISCLAIMER OF LIABILITY ► PLEASE READ AND SIGN THIS DISCLAIMER OF LIABILITY I have adequate medical coverage and insurance and give my child permission to attend The NYC Shabbaton 2020 feb 26- March 1st 2020 and we (or I) agree to indemnify The Organizers its Directors, Staff & Chaperones, and all its officers, coaches and members for any claim which may hereafter be presented by our (or my) child as a result of any such injuries. Parent Guardian Name Participant Name Date STEP 4: HEALTH | EMERGENCY INFO ► INSURANCE INFO Insurance Co. Policy # EMERGENCY INFO Name (not a parent) Tel Please provide details for applicable items pertaining to your child. Allergies (Food, drug, insect or substance) Current Medication(s) or Medical Treatment Recent illness, injury or surgery Disability, chronic illness or condition Activity restriction or modification ► STATEMENT AND EMERGENCY AUTHORIZATION I (the parent or legal guardian) of the applicant state that he/she is in good/normal health, has no physical or mental handicaps that would interfere with full participation in the program and has my permission to engage in all available activities except as noted under Restrictions or Modifications above. I have been made aware of the fact that the events in which the likeness of my child is participating may be photographed by either amateur or professional photographers, and that the photographs may be used for purposes of reporting on the event, future publications or promotional material use. In case of a medical emergency, accident or health problem where immediate treatment is deemed necessary, every effort will be made to expeditiously contact the parent(s) or guardian(s) of the participant, or the emergency contact person listed above. In the event I cannot be reached, I hereby give permission to the physician selected by The Organizers its Directors, Staff & Chaperones, or his/her designee, to hospitalize, secure proper and ongoing treatment and to order injection, anesthesia, or surgery for my child as named above. I fully agree to assume any financial responsibilities that may result from the aforementioned decision taken by the aforementioned individuals. I am aware that this form may be photocopied for use by medical caregivers. ► SIGNATURE OF PARENT OR LEGAL GUARDIAN Name Date This page uses 128 bit SSL encryption to keep your data secure.
