Ignite Detailed Registration Form 2020-2021

Bar/Bat Mitzvah Student's Information

Student's Name *

First Name Last Name

Birth Date *

Month Day Year

School *

Grade *

Bar/Bat Mitzvah Date

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Gender

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Student's Phone Number

Area Code Phone Number

Student's Email

example@example.com

Parent/Guardian Information

Father's Name *

First Name Last Name

Mother's Name *

First Name Last Name

Father's Cell Number *

Area Code Phone Number

Mother's Cell Number *

Area Code Phone Number

Father's E-mail *

Mother's Email *

example@example.com

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

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

Details

1. Each Bar/Bat Mitzvah will be matched with their Guide
(Counselor) to work with throughout the program. Their
Guide will work to help them process everything in a
way that is most suited to their strengths and interests.

2. Each Bar/Bat Mitzvah will be given homework
after each group trip to stimulate them to process
what they have experienced. They will review their
work with their Guide in the Individual sessions.

3. During Individual sessions, the Bar/Bat Mitzvah can
work on additional goals with their Guide. However,
this program in NOT designed to teach Bnei Mitzvah
students large amounts of Torah or Tefilla reading.

4. The goal for each group trip is to have the Bnei Mitzvah
working in settings that will educate them in meaningful
Jewish values. Most of the group trips will involve the Bnei
Mitzvah volunteering as a group in one or more settings.

5. A calendar containing the dates of the group trips will
be given out at the beginning of the program and a
complete itinerary for each group trip will be sent a
week or two in advance. Expect each group trip to be at
least a half day trip. The final trip will be 2-3 days long.

6. We will encourage our graduates to stay connected
and share their ongoing commitments with each other
in effort to inspire lifelong involvement in Judaism.

7. The cost for the Bnei Mitzvah for Life program is $1,800
for each Bar or Bat Mitzvah child (excluding airfare,
approximately $300).

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Southeast Center for Judaism during the Ignite Program. In exchange for the acceptance of said child’s candidacy by Southeast Center for Judaism in the Ignite Program. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Southeast Center for Judaism 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 Ignite 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 Southeast Center for Judaism 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.

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. *

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My Products

Pay in 8 Installments $ 225.00

Pay in full upfront $ 1,800.00

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