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Submission #321

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Submission Information
Submitted by Anonymous
Wednesday, April 27, 2011 - 11:32pm
117.7.10.21
Please enter the last name and first name of the first camper you are registering. Use the format Last name, First name.
MaleFemale
Is Camper 1 a male or female?
The sex of Camper 1
Birth date of Camper 1
The name of the school Camper 1 is currently attending.
What is Camper 1's e-mail address?
What grade will Camper 1 enter in September, 2010?
Please enter the last name and first name of the second camper you are registering. Use the format Last name, First name.
MaleFemale
Is Camper 2 a male or female?
The sex of Camper 2
Birth date of Camper 2
The name of the school Camper 2 is currently attending.
What is Camper 2's e-mail address?
What grade will Camper 2 enter in September, 2010?
The name of Parent/Guardian 1. Please use the format Last name, First name.
The street address of Parent/Guardian 1
The home phone number of Parent/Guardian 1
The work phone number of Parent/Guardian 1
The cell phone number of Parent/Guardian 1
The e-mail address of Parent/Guardian 1
What is the occupation of Parent/Guardian 1?
The name of Parent/Guardian 2. Please use the format Last name, First name.
The street address of Parent/Guardian 2, IF IT IS DIFFERENT FROM THE ADDRESS OF PARENT/GUARDIAN 1
The home phone number of Parent/Guardian 2 IF IT IS DIFFERENT FROM THE HOME PHONE NUMBER OF PARENT/GUARDIAN 1
The work phone number of Parent/Guardian 2
The cell phone number of Parent/Guardian 2
The e-mail address of Parent/Guardian 2
What is the occupation of Parent/Guardian 2?
To what congregation does your family belong?
What is the affiliation of your congregation?
Does your child have any special needs or conditions that might affect his/her ability to integrate fully in our program?
If yes, please explain and if you have registered more than one child on this form, indicate which child.
By selecting 'yes' you are agreeing to the following: • I hereby give my child permission to attend JRF WEST Mini Camp at JCA Shalom and participate in all activities • I understand that $250 of each registration is non-refundable • I understand that if I cancel my registration after June 1, 2010 I will still be responsible for 100% of camp fees.
Would you like to make a voluntary tax deductible donation to the JRF WEST Mini Camp Scholarship Fund?
Do you need a scholarship to help defray the cost for your camper to attend JRF WEST Mini Camp?
$
A deposit of at least $250 is required to process your registration. Please enter the amount of the deposit you are paying to JRF at this time.
$
I am making a Scholarship Donation in this amount.
How would you like to pay for JRF WEST Mini Camp?
I hereby give permission to my child(ren) to participate in the JRF WEST Mini Camp and do release JRF, Shalom Institute (the camp venue), and their respective representatives from all liability arising out of my child’s participation in this activity. I acknowledge that my child’s participation in Camp, and activities such as rock climbing, ropes or challenge course, trust falls, team initiatives, hiking, camping, horseback riding, field trips, sports, and swimming, as well as any other activities, entails known and unanticipated risks which could result in physical or emotional injury or damage to my child, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I expressly agree and promise to accept and assume all risks of such activities. My child’s participation in this activity is purely voluntary, and I elect to have my child participate in spite of the risks. JRF, Shalom Institute, and their respective representatives may use any photograph, slide, video or likeness of my child for camp publicity or other publications associated with the camp. JRF, Shalom Institute, and their respective representatives accept no responsibility for loss or damage to any student’s property during the retreat. At the discretion of the camp director, my child may be sent home because of behavioral problems, the bringing of alcohol, drugs, and/or cigarettes to camp. I agree to have our name, address, e-mail, and phone number listed on a retreat roster to be distributed to all families. I understand and agree that if my child becomes ill or incapacitated, JRF, Shalom Institute, and their respective representatives, or my child’s group leader, may take any action they deem necessary for my child’s safety and well-being, including securing medical treatment and I release JRF, Shalom Institute, and their respective representatives from all liability arising out of such actions. Specifically, in consideration of the opportunity to attend Camp, I agree for me, my child, and other parent or legal guardian, if one, to release, indemnify and hold harmless JRF, Shalom Institute, and their respective affiliates officers, directors, representatives, agents and employees and all other persons or entities acting in any capacity on JRF’s and/or Shalom Institute’s behalf (the “Released Parties”) from, and agree not to sue the Released Parties for, any claims that I or my child may have arising from, or in connection with, any personal injury, bodily injury, mental anguish, emotional distress, physical, property or other damage that I or my child may suffer from any cause whatsoever related in any way to my participation in this JRF camp, including securing medical treatment for my child. Without limiting the generality of the foregoing, I release, indemnify, and hold harmless the Released Parties from, and agree not to sue them for any personal injury, bodily injury, mental anguish, emotional distress, physical, property or other damage that I or my child may suffer from the Released Parties’ negligence arising from or related to my child’s participation in Camp, including travel thereto and JRF’s and Shalom Institute’s securing or authorizing medical treatment for my child. I represent and confirm that I have adequate insurance to cover any injury or damage my child sustains while participating in Camp and understand JRF and Shalom Institute rely on that fact. I further represent that my child has no medical or physical conditions that could interfere with her/his safety or health while engaging in Camp, including any camp activities. I have read, and fully agree to the JRF WEST Mini Camp Registration Form.