Boarder Permission Form

Parent Email*

NOTE: If you have more than one child, please submit this form for ONLY ONE of your children. After you submit the form once, there will be a link to add more children. You will NOT have to re-enter your emergency contact information if you use this link.

Student Information

Student LEGAL Name*

First NameLast Name

Birth Date

MonthDayYear

Grade for 2020-2021*

Emergency Contact Information for Host Family

1st Contact*

First NameLast Name

1st Relationship*

1st Preferred Number*

Area CodePhone Number

1st Secondary Number

Area CodePhone Number

2nd Contact*

First NameLast Name

2nd Relationship*

2nd Preferred Number*

Area CodePhone Number

2nd Secondary Number

Area CodePhone Number

3rd Contact

First NameLast Name

3rd Relationship

3rd Preferred Number

Area CodePhone Number

3rd Secondary Number

Area CodePhone Number

Medical Emergency Information - for Host Family

This information will be kept confidential and will be used only in the case of emergency.

For your daughter’s safety, it is imperative that the host family know about ALL medical conditions.

YesNo

Please explain what the condition is (include any chronic illness or physical limitation):

YesNo

Please list:

YesNo

Please list name and dose:

TylenolMotrinBenadrylNone of the above

Health Insurance Verification

I verify that my daughter currently has health insurance coverageI verify that my daughter DOES NOT have health insurance coverage

I will scan & upload a copy of my card belowI will bring my insurance card to Temima to be scanned

Upload Health Insurance card

Upload File(s)

Medical Release for Host Family

By signing below, I hereby give parental permission to the host family to act “in loco parentis” in case of medical emergency.

Indemnification and Release of Liability

This INDEMNIFICATION AND RELEASE OF LIABILITY is given by the above named Student and the below named Parent (individually and collectively referred to herein as “BOARDER”) in favor of Temima: The Richard and Jean Katz High School for Girls, Inc. (“TEMIMA”).

In consideration of BOARDER’s boarding at a home, the Boarder agrees to indemnify, forever defend, save, and hold TEMIMA, its officers, directors, trustees, employees, members, and agents harmless from and against any and all liability or loss, including attorney’s fees, due to death or personal injury to any person, or from damage to the property or any other person, association, or corporation, arising from or out of the BOARDER’s temporary occupancy and/or use of OWNER’s premises, with the exception of any such death, injury, or damages caused by the intentional or negligent acts of OWNER.

BOARDER further agrees that none of TEMIMA, its officers, directors, trustees, employees, members, and agents shall be liable to BOARDER in damages or otherwise for injury loss suffered by any person, including BOARDER, arising from any defect in the construction, maintenance, or operation of the Property, and BOARDER hereby releases, covenants not to sue, indemnifies, and agrees to hold harmless TEMIMA, its officers, directors, trustees, employees, members, and agents therefor.

This Indemnification and Release of Liability shall remain in effect for as long, and as often, as BOARDER enters and/or engages in any activities on the Property.

Confirmation

By affixing my signature below, I hereby acknowledge that I accept all of the terms and conditions of each and every one of the forms above, specifically including the Medical Release for Host Family and the Indemnification and Release of Liability.

I also acknowledge that by affixing my signature below, I am delivering an electronic signature that will have the same effect as an original signature on paper or other hard-copy. The electronic signature is equally as binding, and shall have the full force and effect, as a signature on paper or other hard-copy.

Name of Parent Signing Below*

First NameLast Name

Date*

MonthDayYear

Signature (Click and drag)*

Boarder Supplemental Permission Form for 2020-2021