JTI Permission and Registration Form - L'Taken/DC Trip 2020
If you would prefer to fill out a paper form, please contact us at info@jtiboston.org
I give permission for my son/daughter to participate in the L'Taken/Washington, DC Trip on February 21-24, 2020 *
Type your son/daughter's name
Your answer
I acknowledge that the participation of my child (listed above) in the L'Taken/Washington DC Trip is voluntary and may result in personal injury or property damage. I understand and assume, on behalf of my child, all risks relating to participation in this event and agree that Jewish Teen Initiative of Greater Boston (JTI) and its employees, directors, officers, agents, representatives, independent contractors, licensees and sponsors (collectively, the “Releasees”) shall not be responsible for any personal injury, property damage and/or other loss suffered as a result of my child's participation in any of the individual activities (an “Injury”). I understand by signing below on behalf of my child, and in consideration of being permitted to participate in the volunteer activities, I forever release each of the Releasees from any and all liability arising from an Injury. *
I hereby empower JTI staff to act for me in accordance with their best judgment in case of emergency. I hereby authorize the physician selected by a JTI staff person to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child named above. *
I understand that my child's picture may be taken at this event, and that it may appear on the JTI website, social media or in a brochure *
I have read and signed the Code of Conduct and witnessed my child signing it. *
You can access the Code of Conduct in the sidebar of the registration page
*
Type your name to sign
Your answer
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
Gender *
Your answer
Birthdate *
Your answer
School Name *
Your answer
School Type *
Graduation Year *
Temple/synagogue affiliation, if any
Your answer
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 1 email address *
Your answer
Parent/Guardian 2 name
Your answer
Parent/Guardian 2 cell phone number
Your answer
Parent/Guardian 2 email addresses
Your answer
Emergency Contact (should be someone other than a Parent/Guardian) *
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
How did you learn about this trip? *
Check all that apply
Required
Signature of Parent or Guardian *
Your answer
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) as well as your deposit.

You can pay using PayPal (link in sidebar of registration page) or you can mail a check to:

Jewish Teen Initiative
6 Community Road
Marblehead, MA 01945
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