BAJY Sleepover at Beth Am - Form - Congregation Beth Am

* Are You a Member of Beth Am?

Please Select OneYes, I am a Beth Am MemberNo, 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

Tween Information

* Tween Legal First Name

Tween Prefered Name (Nickname)

* Tween Last Name

* Tween Grade

Please Select One6th7th8th

* Tween Pronouns

* Teen Email

* Teen Cell Phone

* Home Street Address

* Home Address City

* Home Address Zip Code

Medical Information

Please List All Allergies Your Tween Has

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

Please List All Medications That Your Tween 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 Tween

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 Tween's Vaccination Card*

*Please note that all participants are required to be vaccinated and boosted.

Please List Any Dietary Restrictions/Concerns Your Tween Has

Please note: Beth Am is "Kosher-Style" so we will not have any pork or shellfish.

* Would You Like to Register Another Tween?

Please Select OneNoYes, Register Another Beth Am TeenYes, Register Another Non-Beth Am Teen

* 2nd Tween Legal First Name

2nd Tween Prefered Name (Nickname)

* 2nd Tween Last Name

* 2nd Tween Grade

Please Select One6th7th8th

* 2nd Tween Pronouns

* 2nd Tween Email

* 2nd Tween 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 Tween

Please List All Allergies Your 2nd Tween 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 Tween

Please List All Medications That Your 2nd Tween 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 Tween

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 Tween's Vaccination Card*

*Please note that all participants are required to be vaccinated and boosted.

Please List Any Dietary Restrictions/Concerns Your 2nd Tween Has

Please note: Beth Am is "Kosher-Style" so we will not have any pork or shellfish.

Permissions and Liability

* Who is Allowed to Pick Up Your Tween(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 Tweens You are Registering for the Late Night or Overnight

Overnight

Late Night

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 OneRegistering 1 TweenRegistering 2 Tweens.

Total Event Cost