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BAJY Sleepover at Beth Am


Parent/Guardian Information


 Additional Parent's or Guardian's information. 


Tween Information




Medical Information

Please include severity of the allergy and an action plan in the event of exposure. 
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. 

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 note that all participants are required to be vaccinated and boosted. 
Please note: Beth Am is "Kosher-Style" so we will not have any pork or shellfish.




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. 

Medical Information for 2nd Tween

Please include severity of the allergy and an action plan in the event of exposure. 
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. 

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 note that all participants are required to be vaccinated and boosted. 
Please note: Beth Am is "Kosher-Style" so we will not have any pork or shellfish.

Permissions and Liability

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.

This consent applies to all children you are registering

Financial Section

   Overnight
   Late Night

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Sun, February 5 2023 14 Sh'vat 5783