Summer Adult Rec Registration Form

All adult summer programs are open to anyone aged 21 years and older. Please complete this form to submit your registration for the summer. Billing and payment will follow afterwards.

Participant Contact Details

Participant's Name *

First Name Last Name

Participant Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Participant Cell Number *

Participant E-mail *

example@example.com

Emergency Contact's Name *

First Name Last Name

Relationship *

Emergency Contact's Phone Number *

Summer Program Line Up

Below are various events taking place this Summer. Please note that the times listed are for the program's start & end time. The times reflected do not include transportaion. You will receive an email with times for transportation as each event date gets closer.

Cubs Baseball Game - Cubs vs. Braves
Friday, June 17
1:20pm-4:30pm (approx. end time)
Cost: $55 per person (includes ticket to the game)

I am interested in the baseball game event:

Yes No

Do you want transportation for this event? There is an additional cost of $20.

Yes No

Please select a pick up/drop off location.

Skokie (Keshet Gadol: 8140 McCormick Blvd) Northbrook (Keshet Business Office: 610 Academy Dr)

Ravinia Festival: Lion King Movie with Live Orchestra

Wednesday, June 29

7:00pm-9:00pm

Cost: Free (RSVP required) . Includes Ravinia Ticket, Kosher Food and Beverage

I am interested in the Ravinia Festival event:

Yes No

Do you want transportation for this event? There is an additional cost of $20.

Yes: No

Please select a pick up/drop off location.

Skokie (Keshet Gadol: 8140 McCormick Blvd) Northbrook (Keshet Business Office: 610 Academy Dr)

Fitness Day at Z Frank Apachi
Monday, July 6
6:00pm-8:00pm
Cost: Free

I am interested in the Fitness Day event:

Yes No

Do you want transportation for this event? ONLY AVAILABLE FROM SKOKIE--There is an additional cost of $10.

Yes No

Top Golf-Schaumburg

Sunday, July 10

10:30am-12:30pm

Cost: $45 per person (Includes 2 hours of game play, 1 free alcoholic beverage & Kosher snacks/drinks)

I am interested in the Top Golf event:

Yes No

Do you want transportation for this event? There is an additional cost of $20.

Yes No

Please select a pick up/drop off location.

Skokie (Keshet Gadol: 8140 McCormick Blvd) Northbrook (Keshet Business Office: 610 Academy Dr)

Beach Day at Loyola Beach
Friday, July 15
11:00am-2:00pm
Cost: Free

I am interested in the Beach Day event:

Yes No

Do you want transportation for this event? There is an additional cost of $20.

Yes No

Please select a pick up/drop off location.

Skokie (Keshet Gadol: 8140 McCormick Blvd) Northbrook (Keshet Business Office: 610 Academy Dr)

Create Your Own Dinner at Gadol
Wednesday, July 20
4:30pm-6:30pm
Cost: $30 per person (includes food & drink)

I am interested in the Create Your Own Dinner event:

Yes No

Do you want transportation for this event? ONLY AVAILABLE FROM NORTHBROOK--There is an additional cost of $10.

Yes No

Six Flags Great America in Gurnee
Sunday, July 24
9:00am-6:00pm

Cost: $50 per person (includes admission ticket)

I am interested in the Six Flags Great America event:

Yes No

Do you want transportation for this event? There is an additional cost of $20.

Yes No

Please select a pick up/drop off location.

Skokie (Keshet Gadol: 8140 McCormick Blvd) Northbrook (Keshet Business Office: 610 Academy Dr)

Lunch in Central Park, Skokie
Friday, August 5
12:00-2:30

Cost: $10 per person

I am interested in the Lunch in the Park event:

Yes No

Do you want transportation for this event? ONLY AVAILABLE FROM NORTHBROOK-There is an additional cost of $10.

Yes No

Shabbat Happy Hour at ICJA in Skokie
Friday, August 12
3:30pm-5:00pm
Cost: $10 per person (includes food, alcoholic beverages & music)

I am interested in the Shabbat Happy Hour event:

Yes No

Do you want transportation for this event? ONLY AVAILABLE FROM NORTHBROOK-There is an additional cost of $10.

Yes No

BBQ, Beverages & Board Games in Northbrook
Wednesday, August 17
5:00pm-7:00pm
Cost: $10

I am interested in the BBQ, Beverages & Board Games event:

Yes No

Do you want transportation for this event? ONLY AVAILABLE FROM SKOKIE. There is an additional cost of $10.

Yes No

About the Participant

Participant Birthdate

Participant Gender

Participant Lives: *

With a parent/guardian CILA or community residence On their own

Name of Residence and Agency operating the residence *

Will the participant require us to provide 1:1 staff to support them at the programs? An additional fee to cover staffing will be assessed.

Yes No The participant requires staff but it will be provided

Does the participant have any allergies or any special diets?

Yes No

Please share the what allergies or special diets the participant has and what if any reaction happens and any other details on a care plan that exists.

Does the participant use a mobility device or require a physical accommodation?

Yes No

The participant uses a

Does the participant have a history of seizures?

Yes No

Please upload the participants Seizure Action Plan

Please use the space below to outline any medical conditions or any anything else we would need to know about the participant when they are out programming.

To participate in programming, participants must be up to date with their COVID-19 vaccinations, provide proof of such and be able to wear a face covering when indoors or when outdoors within 6 feet of others. At all other times, face coverings are optional. You attest the above statement is:

True False

Please upload participant COVID-19 Vaccination Card

Disclaimers, Waivers and Permissions

By registering for our Adult Summer programs you give Keshet and it's affiliates permission to work with the participant and provide a high quality of care while at our programs.

You agree to:

- Disclose any personal information relating to the participant to best set us up for success

-Allow the participant to participate in the programs selected, be in the determined program locations and be transported by Keshet and it's approved vendors.

- Allow Keshet to use photographs, videos, audio, and other information for outside publicity and/or educational purposes on their website(s) and other social media outlets. And understand that these materials will remain the property of Keshet and that neither the volunteer nor their parent/guardian will be entitled to any type of compensation or payment for the use of these materials.

- Allow Keshet and it's desingated affiliates to administer any medications necessary to the participant during program time.

- Allow Keshet and it's designated affiliates to provide basic first aid and seek medical treatment and emergency transportation in the event of an emergency.

- Assume full responsibility for any risk of personal injury, property damage or death due to any negligence of Keshet its employees, agents, servants, officers, directors, volunteers, members, or participants in the activity in which the participant participates, while engaged in such activities upon said premises and covenant not to sue Keshet, its employees, agents, servants, officers, directors, volunteers or members, for or on account of personal injuries, property damage or death resulting from personal injury in consideration of the privilege of the volunteer entering upon said premises and participate in such activities. It is my express and specific desire to allow the participant to participate in the activity of the Keshet Recreation Programs. It is my clear and specific intent by executing the signed permission form to release Keshet its employees, agents, officers, directors, volunteers and members from any and all liability for personal injury caused by to any negligence of Keshet, its employees, agents, servants, officers, directors, volunteers or members.

-Understand that Keshet has implemented safety precautions and has complied with all federal, state, and local guidelines intended to prevent the spread of COVID-19 but cannot guarantee no exposure to the virus.

-Participants must be up to date on their covid vaccinations. Face coverings are not required when outdoors but are optional. When indoors and distance not maintained, face coverings are required.

-Remit payment for registration promptly for program participation. All programs are pay in full. Refunds will not be issued.

I have read thoroughly the terms above and voluntarily agree to sign the within Permission Form and Release and Waiver of Liability and have agreed not to hold others liable for any injuries the participant might sustain.

Signature

Clear

Date