Ignite Detailed Registration Form 2021-2022

Bar/Bat Mitzvah Student's Information

Student's Name *

First Name Last Name

Birth Date *

Month Day Year

School *

Grade *

Bar/Bat Mitzvah Date

Date

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

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 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).

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

Yes No

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 Ignite Program. In exchange for the acceptance of said child’s candidacy by Aish of the Rockies in the Ignite 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 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 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.

COVID 19 Waiver and Assumption of Risk

To the Members and people who use are going to be using the Aish Building located at 9550 E Belleview Ave, Greenwood Village, CO, including all of its facilities, or joining any of the Aish, and/or joint Aish and NCSY, in-person programming.

Due to the 2019, 2020 and 2021 outbreak of the novel Coronavirus (COVID-19), Southeast Center for Judaism, Inc. d/b/a Aish of The Rockies is taking extra precautions with the care the building and facilities to enhanced sanitation/disinfection procedures in accordance with the Colorado Department of Public Health and Environment including working closely with the Centers for Disease Control and Prevention.

(CDC) Symptoms of COVID-19 might include:

Fever. Fatigue. Dry Cough. Difficulty Breathing. Muscle aching. Loss of taste and/or smell.

(The above list is not exclusive and if any doubt as to your health status, please consult with a medical provider of your own choice)

In consideration of the use of the Aish Building, or joining any of the Aish and/or joint Aish and NCSY in-person programs whether at the Aish building or any other location, it is agreed:

1. I, herein after called the acknowledging Party, understand the above symptoms, and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS.

2. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 14 DAYS.

3. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 14 DAYS.

4. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS.

5. I agree and affirm that I will thoroughly wash my hands before and after entering and leaving the Aish Building.

6. I understand, covenant and agree that Aish of the Rockies and NCSY, it employees, officers, directors and/or members cannot be held liable for any potential or actual exposure to the COVID-19 virus and I assume all risk of any type associated with the use of the Aish Building and/or of any facilities, and with joining any in-person programming at any location. I understand there is a constant present and active risk that I or who ever else uses the Aish Building or joins an in-person program at any location, may be exposed to the COVID-19 Virus and I voluntarily assume this risk, covenant and agree not to sue and/or to enforce a judgment against Aish of the Rockies and/or NCSY voluntary waiving any and all claims. In reliance to the covenants and agreements, Aish of the Rockies will allow you the use of the Aish Building and/or its facilities and to join in-person programming at any location, in accordance with its rules, regulations, and schedules. No other person my use the Aish Building or join in-person programming at any location except acknowledging party

7. I agree to each statement above and fully and completely assume any and all risks of any and all types during my use of the Aish Building and/or participation at in-person programming in any location. This agreement will stay in full force and effect until withdrawn by Aish of Rockies. This agreement is binding on the acknowledging Party, his/her heirs, assigns and succors according to the laws of the State of Colorado.

8. Members or Users in using the Aish Building and its facilities and participants in Aish and joint Aish and NCSY in-person programming do hereby covenant and agree to indemnify to the greatest extent allowed by law and will forever defend any claims made by any party for claimed injuries, damages or any kind of loss for COVID 19 made against Aish of Rockies, NCSY, their Rabbis, officers, directors, members, employees or independent contractors that provide services to Aish of the Rockies and/or NCSY because of the use of the Aish Building and/or participation in in-person programming by the Acknowledging Party Member or User.

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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