Registration & Permission Form: Pool Party, August 20, 2019
Join us at the outdoor pool at JCCNS (4 Community Rd in Marblehead) to mark the end of the summer and see all your friends from camp, Israel, and other programs! All teens grades 8-12 are welcome at this free gathering!
I give permission for my child to participate fully in the Pool Party on August 20, 2019. *
Type your son/daughter's name
Your answer
*
Type your name to sign
Your answer
I hereby empower JTI, JCCNS and/or Temple Partner staff to act for me in accordance with their best judgment in case of emergency. I hereby authorize the physician selected by a JTI/JCCNS staff or Temple Partner staff person to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child named above. I have also read and signed the Code of Conduct and witnessed my child signing it. *
Participant’s Last Name *
Your answer
Participant’s First Name *
Your answer
Home Address *
Street, Town, State and Zip Code
Your answer
Participant email address *
Your answer
Birthdate *
Your answer
Graduation Year *
School Name *
Your answer
School Type *
Participant's cell phone number
Your answer
Participant's home number
Your answer
Parent/Guardian 1 Name
Your answer
Parent/Guardian 1 cell phone number
Your answer
Parent/Guardian 2 name
Your answer
Parent/Guardian 2 cell phone number
Your answer
Parent email addresses *
Separate multiple addresses with a comma
Your answer
Emergency Contact (if Parent/Guardian 1 & 2 are unreachable)
Contact name & relationship to teen
Your answer
Emergency Contact Phone Number
Your answer
Participant's Primary Care Physician's Name
Your answer
Participant's Primary Care Physician's Phone Number
Your answer
Insurance Company
Your answer
Are there any special medical or dietary concerns or limitations to your child’s full participation in our youth program? (All information is completely confidential.)
Your answer
Signature of Parent or Guardian *
Type your name below to sign
Your answer
How did you hear about this event? *
Required
Important next steps - your registration is not yet complete
In order to reserve your space, we must have your completed forms (this and our Code of Conduct)

We look forward to celebrating the end of an amazing summer with you!

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