CCM Winter 2022: Health Screen & Waiver for Wednesday Nights
Shalom! We are excited to hold another week of Midrasha for 8-12th Graders this upcoming Wednesday from 7:15 - 9:15pm at B'nai Tikvah - 25 Hillcroft Way, Walnut Creek Ca., 94597

A few reminders about the event:
- This event is for 8-12 Grade teens.
- Teens are asked to attend as vaccinated individuals.
- All attendees are required to wear a mask while at the event.
- We are going to have yummy food at this event. When eating, participants don't need to wear masks but we do ask for social distancing and respect.
- Attendees should bring a mask, a hoodie or jacket, and a readiness to have fun!

Please fill out this form in advance of your teen arriving at the Opening Night.

Additionally, if you have not already done so, please send a copy of your teen's vaccination card to office@ccmidrasha.com. Thank you!

By filling out this form, the adult and teen agree to abide by the regulations for meeting in person as per https://www.ccmidrasha.com/covid-19 and to maintain the healthy and safety of all while we are together.

Sign in to Google to save your progress. Learn more
Email *
Date? (dd/mm/yyyy) *
Person Answering Questions *
Teen/s attending Midrasha: *
In the last 14 days have you, your CCM teen/s or anyone in your household: *
Note: If you, your teen or any member of your household has experienced any of the following symptoms, we kindly ask that you stay home this week.
Required
In advance of being in person - is there anything we need to do about your teen in order to make our time together as positive as possible?
CCM Waiver
PLEASE READ CAREFULLY. THIS DOCUMENT EFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING CONTRA COSTA MIDRASHA AND THE WEISS-ISHAI FAMILY FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFORE

Assumption of Risk
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. As a result, federal, state, and local governments and agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. We are doing everything we can to be compliant with all regulations and ensure your safety. We have put in place preventative measures to reduce the spread of COVID-19, but we cannot guarantee that you or family members will not become infected with COVID-19.

I, in my legal capacity as the parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of the Weiss-Ishi home (“Organization”) facilities, services, equipment and premises (“Facilities”) and any participation in Organization programs and activities of Contra Costa Midrasha (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.

Waiver, Release, Indemnification & Covenant Not to Sue
In consideration of Minor’s use of Facilities and participation in Programs I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that the Organization, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or death sustained from the use of Facilities and participation in Programs.

I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees.

In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs.
By typing your name and your teen/s name/s into the box below, you affirm to the agreements of the above waiver. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Contra Costa Midrasha. Report Abuse