10th Grade Shabbaton 2023

10th Grade Galveston Shabbaton

January 27-28, 2023
Teen Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Teen Phone Number*
Please enter a valid phone number.
Parent/Guardian Phone Number*
Please enter a valid phone number.
Teen Email*
example@example.com
Parent/Guardian Email*
example@example.com
Teen Pronouns
Teen Gender Identity*

FemaleMaleNon-BinaryPrefer not to sayOther
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Information - Kehillah High Student

As a Kehillah High student, I will submit a $200 refundable deposit via check to Congregation Beth Israel. I understand that this check will only be processed if I cancel after Friday, January 20.

Medical Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship to Participant*
Emergency Contact Phone Number*
Please enter a valid phone number.
Please upload the front and back of the participant's insurance card here.

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Current medications:*
Teens will be responsible for holding onto their medication and administering it themselves.
Allergies - food, environment, medical, etc.*
Dietary needs:*
We are so excited to continue our overnight experiences at Kehillah High! To maintain everyone's safety against COVID-19, we are requiring that all participants be fully vaccinated (two weeks out from their booster). Please upload an image or scan of both sides of your vaccination card below.
Please upload the front and back of your COVID-19 vaccination card here.*

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WAIVER AND RELEASE

I have voluntarily chosen to participate in Kehillah High's 10th Grade Shabbaton (“Program”), I understand that there are risks associated with my participation in such a Program, including without limitation risks associated with outdoor activities, sporting activities, overnight stays, transportation, and travel. I acknowledge that the nature of the Program may expose me to hazards or risks that may result in my illness, personal injury, or death, and I understand and appreciate the nature of such hazards and risks. In consideration for and as a condition to my participation in the Program, I hereby accept all risk that may result from my participation in the Program, and I hereby fully and unconditionally release and forever discharge Kehillah High and its respective affiliated entities, governing boards, trustees, directors, officers, employees, volunteers, advisors, parents/legal guardians or other chaperones, administrators, faculty, attorneys, agents, insurers, representatives and any other person acting by, through, under or in concert with any of such persons or entities, and their successors and assigns (collectively referred to herein as “the Organizer”), from any and all liability to me, all members of my family, my personal representatives, estate, executors, administrators, heirs, next of kin and successors and assigns for any and all claims and causes of action for loss of or damage to my property (either owned or rented by me) and for any and all illness or injury to my person, including my death, that may result from or occur during and/or related to my participation in the Program. This release extends and applies to, and covers and includes, all unknown, unforeseen, unanticipated, and unsuspected injuries, damages, loss and liability, and the consequences thereof, occurring in connection with and/or in any way related to my participation in the Programs at any time after the execution of this Waiver and Release.

Food Allergies, Medical Contingencies, and Consent to Treat

I understand and agree that I am solely responsible for providing the Organizer with all relevant medical considerations pertaining to my well-being. I understand and agree that I am solely responsible for any prescribed medications and that I am solely responsible for ensuring that any such prescription medications. I understand and agree that Program staff is not allowed to carry, administer or ensure compliance with any prescribed medication for Program participants, and I understand and agree that special requests—such as the need to refrigerate medication—may be facilitated by Program staff in good faith, but that the Organizer does not accept responsibility for such requests and cannot guarantee that such requests can be granted. However, I recognize that Program staff may administer prescribed medications to a Participant in an emergency situation and may further administer an EpiPen, if available, to a Participant who is showing signs of anaphylactic shock even if that Participant does not possess an EpiPen prescription. I also authorize Program staff to provide over-the-counter medications at their discretion and in their best judgment.

I understand and agree that I am solely responsible for providing the Organizer with all relevant dietary requirements pertaining to my well-being. I understand and agree that Program staff will make a good faith effort to ensure that food is available on the Program that is consistent with any special dietary requirements that I have specified but that I am nonetheless solely and ultimately responsible for food that I consume. Further, I understand and agree that the Organizer cannot guarantee an environment that can or will accommodate me if I have an airborne food allergy. I understand and agree that participation in the Program can be physically challenging and involves irregular sleeping and eating schedules and a highly social environment. I have consulted with a physician and have been advised that I am in good health. I do not suffer from any illnesses, conditions, or disabilities that would make participation in the Program unwise, harmful, or dangerous to myself or others. I understand and agree that should the Program staff determines in their sole discretion that I am not capable of participating in the Program due to physical health or mental-health considerations, I will be removed from the Program and will be fully responsible for my own connecting travel arrangements. I agree that if I become ill or incapacitated the Organizer may take any action it deems necessary for my safety and well-being, including but not limited to securing medical treatment (at my own expense) and making arrangements for transporting me home. I understand and agree that in such instances I will not be entitled to any refund of paid Program fees or costs and that all travel arrangements, costs, and liabilities associated with being returned home, including the cost of an escort, if necessary, will be the sole responsibility of me and my parent/legal guardian.

I hereby authorize the Organizer to charge all such travel arrangements, expenses, and liabilities to the credit card on record with the Organizer. I represent and warrant that I am and will be covered throughout the Program by a policy of comprehensive health and accident insurance that provides coverage within the countries included in the Program for injuries and illnesses I may sustain or experience while participating in the Program, including treatment-related to pre-existing conditions. I understand and agree that, in some countries, the provision of available healthcare services may not meet the standards to which I am accustomed. I further understand and agree that in the event I may need medical care, I may be taken to and receive care from local clinics at the sole discretion of Program representatives. In some instances, healthcare facilities expect upfront payment. I understand that I am responsible for all such payments, whether upfront or otherwise, and I confirm that I have been advised that I should have access to travelers’ checks or a credit card at all times while in such countries in case of a medical emergency.

Taking/Publishing Photographs and Videos

I hereby authorize the Organizer to take and publish photographs/video/quotations taken of me (including printing or otherwise publishing my name in association with such photograph/video or quotation) in printed or electronic format, including but not limited to in publications, presentations, promotions (including those that are mailed), exhibits, press releases, marketing materials, videos, CDs, DVDs, websites (both internal and external) and any social media associated with the Organizer. I acknowledge that since my participation in such photographs/video/quotations is voluntary, I will receive no financial compensation and my participation confers upon me no rights of ownership whatsoever to such photographs/video/quotations. I further understand and agree that such photographs/video/quotations may be shared by the Organizer with third parties consistent with these provisions.
Student Signature*

Clear
Parent Signature*

Clear
Date*

MonthDayYear
Date
STANDARDS OF CONDUCT

I understand and agree that as a participant on Kehillah High's 10th Grade Shabbaton, I am expected to, and will, abide by the directions of all staff as well as the transportation policies, housing and living arrangement policies, substance abuse policies, and other policies and guidelines as may be amended and/or modified from time to time by the Organizer in its sole discretion, without prior notice, and that I am expected to comply with the current laws of the United States (Federal, state and local). These policies include but are not limited to the following areas:

•     I understand and agree that without advanced written parental consent and Program staff approval, no participant is allowed to leave the program from the time of arrival until the completion of the program.

•     I understand and agree that no guests are allowed at this Program without the staff’s prior approval.

•     I understand and agree that curfew means the time at which participants must be in their assigned rooms with lights out and ready for bed. Additionally, I understand that participants may not leave their room between the start of curfew and wake up.

•     I understand and agree that all programs, workshops, services, meetings, and meals are mandatory. Participants will review and follow the program schedule and will remain appropriately staffed and/or in authorized areas.

•     I understand and agree that at no time will any males be allowed to enter a female's sleeping area nor females be allowed to enter a male's sleeping area. Additionally, program staff may designate areas as “single-sex” and these areas are off-limits to participants of the opposite sex

•     I understand and agree that the possession, consumption, purchase, and/or being in the presence of fireworks, firearms or other weapons of any kind, alcohol, tobacco products of any kind, e-cigarettes and “vaping” devices of any kind, illegally controlled substances or other prescription drugs without a valid prescription, gambling, fighting, intimidation, and bullying are grounds for expulsion from the trip and not being able to graduate from Kehillah High

•     I understand and agree that the purchase, possession, and sharing of smoking or e-smoking paraphernalia is not allowed on the program for any reason.

•     I understand and agree that participants are never allowed to share, sell, or otherwise dispense prescribed medication.

•     I understand and agree that I am to be respectful of and towards my peers, staff, and volunteers.

•     I understand and agree that social media must be used responsibly at all times during the program. I understand and agree that in the event of doubt as to what constitutes reasonable use of social media, I will request guidance from staff and will comply with such guidance.

•     I understand and agree that it is expected that participants will behave responsibly and with respect regarding belongings and property throughout the program. Participants must report any property issues or damages in any location to staff immediately. Any unreported damages will be charged to the participant.

•     I understand and agree that proper and respectful attire must be worn at all times. Appropriate footwear must be worn in public spaces.

•     I understand and agree that tattooing or piercing oneself or others or receiving tattoos or piercings, or other forms of self-modification are not permitted on the program for any reason.

•     I understand and agree that any inappropriate physical or verbal contact during the program is not permitted at any time.

•     I understand and agree that if I become aware of any conduct by any participant, volunteer or staff member that I believe is illegal, violates program rules, or creates a risk of harm to any individual or of property damage, I will immediately report the incident to an appropriate Program staff representative.

I understand and agree that Program staff are not responsible for preventing or otherwise policing violations of the above conduct violations and that the Organizer is not responsible for any injury or damage resulting from a violation of these conduct policies.

I understand that my failure to uphold the conduct policy may result in disciplinary consequences, including loss of privileges, separation from the group, termination of my participation (i.e. being sent home), and not be able to participate in graduation from Kehillah High as determined at the sole discretion of the staff. I further understand and agree that the Organizer, as it deems appropriate in its sole discretion, reserves the right (but does not have the obligation) to search my person and/or belongings and to take such action (or to refrain from such action) at it deems appropriate to secure the safety of me and/or others and/or to ensure compliance with the code of conduct, transportation policies, housing, and living-arrangement policies and other policies and guidelines, and that my signature on this code of conduct extends and applies to cover all such actions/inactions. I further understand and agree that I may be required to submit to drug and/or alcohol testing (e.g. breathalyzer or other forms of testing), and that my failure to submit to the requested testing will be grounds for disciplinary action up to and including expulsion; provided, however, I understand and agree that such test need not be administered when the Organizer otherwise reasonably believes that program policy has been violated. I further understand and agree that appropriate legal authorities may be contacted, and I may be subject to possible prosecution or incarceration by the same.

Consequences of Expulsion - I understand and agree that in the event I am expelled from the trip, I will not be entitled to any refund of paid program fees, I further acknowledge that I will be responsible for reimbursing the funding party in full within 30 days of expulsion from the Program. Further, I understand and agree that if I am expelled from the Program, all travel arrangements, costs, and liabilities (including escort costs, if applicable) associated with being sent home will be the sole responsibility of me and my parent/legal guardian, which must be paid up-front.

I further understand and agree that in such circumstances it shall be the sole responsibility of my parent/legal guardian identified below to make immediate arrangements to pick me up at the location designated by the program staff. I further agree that in the event the Organizers incur any costs, expenses, or liabilities for which I or my parent/legal guardian is responsible, and which are not covered or paid for by a credit card on record, The Organizers reserve the right to pursue collection of such costs, expenses and/or liabilities through appropriate collection proceedings.
Teen Signature*

Clear
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10th Grade Galveston Shabbaton

Medical Information