Empower Registration Form 2022-2023

Student's Information

Student's Name*

First NameLast Name

Birth Date*

MonthDayYear

School*

Grade*

Gender

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Student's Phone Number

Area CodePhone Number

Student's Email

example@example.com

Who referred you to Empower?

First NameLast Name

Parent/Guardian Information

Father's Name*

First NameLast Name

Mother's Name*

First NameLast Name

Father's Cell Number*

Area CodePhone Number

Mother's Cell Number*

Area CodePhone Number

Father's E-mail*

Mother's Email*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

If your child has any allergies, chronic illness, or medical conditions, please describe here.

Details

1. Students will meet for 15 sessions throughout the school year at Aish on Sundays from 10:00 am – 12:00 pm for a refreshment social and studying in pairs. There will be additional free bonus sessions at communal events.

2. Empower will have 5 Journeys (Mitzvah Projects) throughout the school year, each one spanning 6 weeks

3. Every Journey will be led by a specialty leader with a connection to the Mitzvah

4. Every Journey will be featured in a professional video

5. There will be a group celebration at the end of each Journey

6. There will be an end of the Year trip to tour NY and present the Journeys to other Jewish students

7. The program cost is $1,200 for annual tuition, plus $500 for the end of the year trip.

Do you give consent for Aish of the Rockies to use photos of your child for marketing purposes?

YesNoOther

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Aish of the Rockies during the Empower Program. In exchange for the acceptance of said child’s candidacy by Aish of the Rockies in the Empower Program. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Aish of the Rockies and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from Empower Program sessions.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Aish of the Rockies and its affiliates including Directors, Guides, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Please call our bookkeeper, Priscilla at (303) 220-7200 for payment options. Thank you.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

By Signing below, you are affirming that you have read the details of this application and that you consent to all of its sections. *