Arvot Kadima Fall Sub-Regional Convention 

“Thing One, Thing Two … Oh the clean things you do!”

Hosted by Greenacres Kadima at the Sheraton Suites Cypress Creek

November 6 - 8, 2009 Forms are due to YD on ____________

Cost $210 - Payable to USY after Oct 19^th Cost $235

Please print clearly:

Name                                      Chapter                               __Grade_                 Gender ________

Address________________________________________ USYer’s Cell# _____________________________________

City _______________________________________________ State _______________  Zip _________________

E-mail ___________________@_______________________    Home Phone Number_________________________

Parent’s Name ______________________________________________________________

Parent’s Cell Phone (mother) _________________________   (father) ____________________________

Parent’s Email (mother)______________@________________ (father)_________________@____________

Shirt Size: Check off size __ S __ M __ L __ XL ___ XXL

List 3 USY’ers who you would like to room with, in order of preference:                                    

1. Name                                                                               Chapter  ________________________

2. Name                                                                                Chapter ________________________

3. Name                                                                                Chapter ________________________

Every effort will be made to honor your mutual requests. Requests will only be considered if forms are received on time. In addition, please understand that no rooming changes will be made before or during any part of the convention.  

Circle one:

Yes   No     Vegetarian - If yes, will you eat chicken, eggs or fish? (Circle those that apply.)

Yes   No     Any allergies or restrictions? If yes, please specify    _______________________

I am interested in leading: (check all that apply)

__ Kiddush                            __ Maariv Shabbat    __ Weekday Shacharit    __ Kabbalat Shabbat

__ Birkat HaMazon              __ Torah Reading      __ Weekday Mincha      __ Haftorah

__ Hamotzi                            __ Shabbat Mincha

SIGNATURES

We have read the attached rules and the applicant agrees to abide by the rules of convention.  We understand that any infraction of the rules could result in the applicant being sent home from the convention at the applicant’s expense.

Signature of Applicant _____________________________________  Date ____________________________

Signature of Parent ________________________________________  Date ____________________________

Signature of Youth Director_______________________________   Date____________________________

APPLICATIONS ARE DUE Back to Regional Office

No Later than Oct 19th

USY Fall Convention

7100 W Camino Real Suite 216

Boca Raton, FL 33433 

Fax # 561-372-0424

CONSENT, AUTHORIZATION, AND RELEASE

RE: __________________ (“MINOR”)                  CHAPTER: ________________________________

Date of Birth: ____________________________

THIS CONSENT, AUTHORIZATION, AND RELEASE (“Consent”) is provided to UNITED SYNAGOGUE YOUTH, SE REGION, a department of the United Synagogue of Conservative Judaism, with regional headquarters in Boca Raton FL (“USY”) in connection with Arvot  Fall Sub Regional Convention, to be held at Sheraton Suite, Cypress Creek, FL Nov 6 - 8, 2009. (“Scheduled Activity”).

1.              The minor has my consent to attend and to participate in the Scheduled Activity.  There are no limitations or restriction of any kind whatsoever on such participation unless this box, _____ is checked with explanation attached to this form.

2.              The Minor has been instructed by me, and understands and agrees, to comply with all rules, regulation, and Codes of Conduct established by USY and the official instructions and directives of all authorized staff members, volunteers, agents, and employees (“Personnel”) of USY.

3.              You are expressly authorized to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions, acting as my authorized agent and at my sole cost and expense.  There are no exceptions or limitations, or other special instructions, in connection with the foregoing, unless this box _____ is checked, with explanation attached to this form.

4.              Unless this box _____ is checked and I have provided you with specific instructions, directions or other specific data to the contrary, on an attached page, you assume that the Minor has no medial disabilities, allergies or other limitations or any kind whatsoever that might in any way limit participation in the Scheduled Activity.

5.              I expressly release and agree to indemnify and hold USY (and its Personnel) free and harmless from any and all liability, charges, claims, costs, and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with the acceptance and participation of the Minor in the Scheduled Activity.  The foregoing Release is without reservation of any kind except only for such acts or omissions on your part that arise out of your intentional or negligent wrongdoing and without fault of any kind on the part of the Minor or on my part in failing to disclose pertinent information to you.

6.              I represent to you that I have the sole, full and legal power and right to execute this Consent, and that you will rely on my representations.

7.              If this consent is signed by more than one person, all references to the singular shall include the plural, jointly and severally.

I DECLARE UNDER THE PENALTY OF PERJURY THAT I HAVE READ AND FULLY UNDERSTAND THE IMPORTANCE AND THE EFFECT OF THE FOREGOING CONSENT, AUTHORIZATION, AND RELEASE: THAT I HAVE OBTAINED SUCH ADVICE OF AN ATTORNEY AND OF A LICENSED PHYSICIAN AS I DEEMED NECESSARY, TO MY COMPLETE SATISFACTION; AND THAT I SIGNED THIS CONSENT ON ___________________, 20___.

Signed __________________________________________________*_____________________________

Signed __________________________________________________*___________________________

Relationship to Minor_______________________________________________________________________________________

Insurance Company Name ____________________________________________________Policy Number __________________

Address ___________________________________________________________________  Phone _________________________

CODE OF CONDUCT

In Connection with the HaNegev Region or any of the affiliated sub regions ( Arvot, Mercaz Ein Gedi):

1. There is to be no smoking.
2. There is to be no possession or use of any narcotics, marijuana, other illegal drugs, or prescription drugs not prescribed for the user.
3. There will be no consumption of any alcoholic beverages.
4. There will be no shoplifting or theft of any kind.
5. If a USYer is caught in possession of/or using alcohol or illegal drugs or is caught shoplifting and/or involved in theft of any kind, he/she will immediately be sent home at his/her parents’ expense.  Furthermore USY International policy states, "if a USYer is apprehended for an infraction of the national youth commission's policy regarding drug and alcohol abuse or any other criminal offense (including, but not limited to, shoplifting) punishment for that offense will include suspension from international USY events (including, but not limited to, the International USY convention and USY summer programs) for one year following the infraction.”  Individuals will also be prohibited from participating in the next major sub/ regional USY program and other events occurring in the interim, and prohibited from chairing events or staffing programs for six months.  Individuals already in leadership positions would be removed.  A major Regional event is a regionally sponsored overnight event, such as a convention, Kinas, or Encampment.  The USYer’s region reserves the right to impose additional sanctions in connection with this or any other improper behavior as it sees fit. 
6. Each participant is expected to maintain proper decorum and attitude during the entire program.  Disruptive behavior (including, but not limited to, inappropriate sexual behavior) will not be tolerated.  Your parents will be responsible to pay for any damage you may cause.
7. No participant may leave the program without the express permission of the director of USY.
8. Each participant is expected to conduct him/herself appropriately as a Conservative Jew (including observance of Shabbat and Kashrut), in accordance with the applicable standards of the Committee on Jewish Laws and Standards of the Conservative Movement and/or the local rabbinic authority.
9. The Region reserves the right to search the room and belongings of any attendee if it has reasonable grounds to believe that such a search is necessary to secure the health, safety and/or welfare of the program and or its participants. The USY Director, in consultation with the regional youth commission, reserves the right to enforce other rules relating to the integrity of the program and/or the safety, health or welfare of its participants.

By my signature, I certify that I will adhere to the program, observe the convention code (which I have read), and will conduct myself in a manner reflecting credit upon my chapter and community. Any violation of this code of conduct may result in the participant being sent home at his/her parents’ expense. The Regional Director has the sole discretion to send a participant home.

Signature Of USYer:              ________________________________________________

I ____________________________________, the parent/ guardian of _______________________________, a minor, who will be participating in the regional programs of (HaNegev) USY, do hereby certify that I have read the Code of Conduct set forth above. I do hereby agree that if my child who has signed the above Rules of Conduct fails to adhere to the Code, then in such event those persons in charge of the program may send my child home at my expense. I understand that the Regional Youth Director has the sole discretion to send my child home.

I have been made aware of the fact that the events in which my child is participating may be photographed by either amateur or professional photographers, which the photographs taken may be used both for purposes of reporting on the event or for such other use as the (Region) USY organization may determine. I have no objection to the pictures taken being used at any time for promotional use. It is my understanding that by signing this document I consent to the use of the pictures just referred to for any purpose whatsoever.

The minor has my consent to attend and to participate in the scheduled activity.  There are no limitations or restrictions of any kind whatsoever on such participation unless this box q is checked with explanation attached to this page.  You are expressly authorized to engage appropriate health care providers to administer, prescribe, and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstance, if you are not able to timely contact me for instructions, acting as my authorized agent and at my sole cost and expense.  There are no exceptions or limitations, or other special instructions, in connection with the foregoing, unless this box q is checked with explanation attached to this page.Unless this box q is checked and I have provided you with specific instructions, directions or other specific data to the contrary, as indicated on this application, you may assume that the minor has no medical disabilities, allergies or other limitations of any kind whatsoever that might in any way limit participation in the scheduled activity. I am aware that this form may be photocopied for use by medical caregivers.

Signature of Applicant _____________________________________________________________________________

PRINT NAME _____________________________________________________________________DATE __________

Signature of Parent/Legal Guardian:_____________________________________________________________________

PRINT NAME:______________________________________________________________________DATE:_________