3rd-6th Grade Shabbaton Registration
Please complete by Wednesday, February 14th!
Student 1 Name *
Your answer
Student 1 Grade *
Student 2 Name
Your answer
Student 2 Grade
Guardian 1 Name *
Your answer
Phone number where guardian can be reached during shabbaton *
Your answer
Does this student have any special medical, emotional, social or other needs that would prohibit him/her from participating in any part of the shabbaton? Your answer to this question will help us ensure the best possible experience for your student and others.
Your answer
Does this student have any special dietary needs?
Your answer
I/we give permission for the above mentioned student to participate in the activities and trips of STS JLC's 3rd - 6th Grade Shabbaton. In consideration of the opportunity of my/our child to participate in the activities of STS JLC's 3rd - 6th Grade Shabbaton, I/we release Shomrei Torah Synagogue, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for any loss or injury to my/our child arising from my/our child’s participation in the activities of the STS JLC 3rd - 6th Grade Shabbaton; and I/we agree to indemnify and hold forever harmless Shomrei Torah Synagogue, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for loss or injury to my/our child arising from activities of the STS JLC 3rd - 6th Grade Shabbaton or resulting from traveling to or from the activities. *
As the parent(s) or legal guardian(s) of the student/s named above, I/we give permission for Shomei Torah Synagogue, its agents,staff, and volunteers to obtain urgent or emergency medical care for my/our child, and I/we authorize health care providers to render such care as may be necessary. It is understood that reasonable efforts will be made to contact me/us prior to obtaining such care, but I/we authorize such care whether I/we are contacted or not, and I/we agree to be financially responsible for such care. *
Do you understand that students are expected to participate in the full 25 hour Shabbaton experience and may not arrive late or leave early from Shabbaton. *
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