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Give
BATY Sleepover at Beth Am (With Late Night Option)
Please verify reCaptcha before submitting the form.
*
Are You a Member of Beth Am?
Please Select One
Yes, I am a Beth Am Member
No, I am not a Beth Am Member
Parent/Guardian Information
*
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Email
*
Parent/Guardian Cell Phone Number
Additional Parent's or Guardian's information.
2nd Parent/Guardian First Name
2nd Parent/Guardian Last Name
2nd Parent/Guardian Email Address
2nd Parent/Guardian Cell Phone Number
Teen Information
*
Teen Legal First Name
Teen Prefered Name (Nickname)
*
Teen Last Name
*
Teen Grade
Please Select One
9th
10th
11th
12th
*
Teen Pronouns
*
Teen Email
*
Teen Cell Phone
*
Home Street Address
*
Home Address City
*
Home Address Zip Code
Medical Information
Please List All Allergies Your Teen Has
Please include severity of the allergy and an action plan in the event of exposure.
*
Please Note Which OTC Medications We Have Your Permission to Administer
Advil (Ibuprofen)
Tylenol (Acetaminophen)
Pepto Bismol
Benedryl
Tums - Calcium Carbonate
None of the Above
Please List All Medications That Your Teen Will Need to Take During This Overnight
All Mediations will be collected by Lauren Bohne, Teen Education Program Director, at the start of the event. Follow up information will be shared on an individual basis.
Please Share Any Physical, Emotional or Behavioral Concerns for Your Teen
This information will be kept confidential. The only goal is for us to be able to ensure a positive and successful event for your teen.
Please List Any Dietary Restrictions/Concerns Your Teen Has
Please note: Beth Am is "Kosher-Style" so we will not have any pork or shellfish.
*
Would You Like to Register Another Teen?
Please Select One
No
Yes, Register Another Beth Am Teen
Yes, Register Another Non-Beth Am Teen
*
2nd Teen Legal First Name
2nd Teen Prefered Name (Nickname)
*
2nd Teen Last Name
*
2nd Teen Grade
Please Select One
9th
10th
11th
12th
*
2nd Teen Pronouns
*
2nd Teen Email
*
2nd Teen Cell Phone
Emergency Contact Information
Please list someone other than the Parent(s)/Guardian(s) listed above to be called in the event of an emergency when you cannot be reached.
*
Emergency Contact Name
*
Relationship to your child(ren)?
*
Emergency Contact Cell Phone Number
Medical Information for 2nd Teen
Please List All Allergies Your 2nd Teen Has
Please include severity of the allergy and an action plan in the event of exposure.
*
Please Note Which OTC Medications We Have Your Permission to Administer to your 2nd Teen
Advil (Ibuprofen)
Tylenol (Acetaminophen)
Pepto Bismol
Benedryl
Tums - Calcium Carbonate
None of the Above
Please List All Medications That Your 2nd Teen Will Need to Take During This Overnight
All Mediations will be collected by Lauren Bohne, Teen Education Program Director, at the start of the event. Follow up information will be shared on an individual basis.
Please Share Any Physical, Emotional or Behavioral Concerns for Your 2nd Teen
This information will be kept confidential. The only goal is for us to be able to ensure a positive and successful event for your teen.
*
Please Upload a Copy of Your 2nd Teen's Vaccination Card*
*Please note that all participants are required to be vaccinated and boosted.
Please List Any Dietary Restrictions/Concerns Your 2nd Teen Has
Please note: Beth Am is "Kosher-Style" so we will not have any pork or shellfish.
Permissions and Liability
*
My Teen Has Permission to Drive Themself to and from This Event
Please Select One
Yes, my teen has my permission to drive to and from the event
No, my teen does NOT have permission to drive to or from the event
This includes permission to drive siblings. Permission to drive or be driven by other teens is separate.
*
Who is Allowed to Pick Up Your Teen(s)
Please list all people who can drive your teen home aside from Parents/Guardians
Permission To Treat Waiver
In the event of an emergency or need for medical treatment, and I cannot be reached, I authorize Beth Am’s staff to act in loco parentis, and to consent to any medical treatment and/or hospitalization deemed necessary for my child(ren). I understand and agree that I will be responsible for the cost of such medical treatment. In addition, I do hereby authorize representatives of Congregation Beth Am as agents for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnoses or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the California Medical Practice Act, whether such examination, diagnoses or treatment is rendered at a physician’s office or at a government licensed hospital. It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment, or hospital care being required, and is given to provide authority and power on any and all such examinations, diagnoses, treatment or hospital care which the aforementioned physician, in the exercise of his/her best judgment,t may deem advisable. This authorization is given pursuant to the provisions of
California Family Code 6910.
I have read the above Release of Liability & Parental Consent for Medical Treatment of a Minor and grant permission for my child(ren)’s participation with such understanding and agreement.
*
Please Type Your Name Below to Certify Your Agreement
This consent applies to all children you are registering
Financial Section
*
Please Select the Number of Teens You are Registering for This Event
0
1
2
3
4
5
6
7
8
9
10
Overnight!
0
1
2
3
4
5
6
7
8
9
10
Late Night
For the Late Night, Teens must be picked up at 10:00 pm
I would like to sponsor this experience for a child who otherwise could not afford to attend!
I would like to sponsor this experience for a child who otherwise could not afford to attend!
*
I Agree to pay the $15 Non-Member Fee
Select One
Registering 1 Teen
Registering 2 Teens
.
Total Event Cost
Sat, April 20 2024 12 Nisan 5784