* Please tell us the names, ages, and grades of everyone who will be attending this event.
Health Insurance Information Please include the health insurance company and policy number for each participant
Please let us know of any dietary restrictions the attendees in your party have.
If your child is bringing medication and/or an epipen with them on the trip, please include details below.
PHOTOGRAPHY AGREEMENT In order to promote our youth programs, we sometimes will use pictures of your child in our synagogue publications or on our Synagogue website. Do you give permission for CBS to use your child’s photograph only in this capacity?YES OR NO :
Lunch at the Park
BEHAVIOR CONTRACT I will either download, print, sign, and send a copy of the behavior contract with my child, or will arrive at CBS by 9:30am on the day of the trip to sign the form.
Find the behavior contract here. (opens in a new window)
PARENT/GUARDIAN CONSENT TO MEDICAL, DENTAL, OR HOSPITAL CARE I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment. As parent or legal guardian of my child, I am responsible for the health care decisions of my child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child is legally sufficient and that no consent from any other person is required by law.
RELEASE, WAIVER, AND INDEMNITY AGREEMENT IT IS THE INTENTION OF ____________________________ (PARENT OR GUARDIAN OF MINOR) BY THIS AGREEMENT TO EXEMPT AND RELIEVE CONGREGATION BETH SHALOM AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF ______________________ (NAME OF MINOR) CAUSED BY ANY ACT OF NEGLIGENCE OF CONGREGATION BETH SHALOM AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES. For and in consideration of permitting __________________________ (NAME OF MINOR) to observe, or use any facility or equipment of Congregation Beth Shalom, or engage in and/or receive instruction in any activity or activity incidental thereto. The undersigned parent and/or guardian of __________________ (NAME OF MINOR): hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to __________________ (NAME OF MINOR) as a result of __________________ (NAME OF MINOR) observing or using facilities or equipment of Congregation Beth Shalom or engaging in or receiving instructions in any activities or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. The undersigned parent or guardian of __________________ (NAME OF MINOR) for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against Congregation Beth Shalom or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless Congregation Beth Shalom and its officers, agents, servants, or employees from any and all claims or causes of action by __________________ (NAME OF MINOR) or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of __________________ (NAME OF MINOR) present any claim against Congregation Beth Shalom and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by Congregation Beth Shalom and said persons. The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
