3rd - 12th Grade Shabbat Retreat
Friday, November 4 - Sunday, November 6

We are at wait list capacity!  Please fill out one form per child attending. Questions? Check out our FAQ page. We can't wait to come together as a community to celebrate Shabbat and connect with one another.
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Participant's Last Name *
Participant's First Name *
Participant's Grade *
Synagogue *
Parent's Name *
Parent's Email *
Parent's Cellphone Number *
What pronouns does your child use (i.e. she/her, he/him, they/them)?
Who would your child like to bunk with?  (More information about cabin assignments is in the FAQs.) *
Is your (post B' Mitzvah) child interested reading Torah? (Parashat Lech-Lecha) *
Is your (post B'Mitzvah) pre-teen/teen interested in leading Kabbalat Shabbat?
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9-12th GRADE ONLY - Are you interested in receiving a leadership certificate*?

*On October 16th from 1 to 3 at Temple Aliyah there will be an opportunity for 9th-12th graders to participate in a pre-retreat leadership training program. Teens who would like to earn a leadership certificate are expected to attended or reach out directly to Nalani Haueter at nalani@templealiyah.com.
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Please list any allergies and medical, physical, or emotional information of which we should be aware. *
Please share anything else you would like to ensure a successful experience for your child/pre-teen/teen. *
I have disclosed my child's physical and mental health above. Please add any additional information below. *

I certify that my child is physically able to participate in the Retreat and I know of no restrictions, physical impairments, or any other condition, other than noted below, which would limit, in any manner, his or her participation in this program.

I give permission for my child to receive emergency medical treatment and/or hospitalization if necessary. I understand that every attempt will be made to contact me  before taking this action.

I give permission for Retreat staff to dispense the prescription medications listed below to my child.  Medication should be delivered to a staff member at pickup and should be labelled with the name of the medication, the name of the child and directions for use.   All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use.  Do not send any more medication than the child is likely to need during the Retreat. Medication will be administered by retreat staff.

I UNDERSTAND THAT THERE IS RISK OF INJURY TO MY CHILD AS A RESULT OF RETREAT ACTIVITIES, AND KNOWINGLY AND VOLUNTARILY ASSUME ALL RISK OF SUCH INJURY.  I will be financially responsible for any medical attention needed during the Retreat or resulting from an injury received while at the Retreat or in transit. My medical insurance shall be the insurance coverage for any medical treatment.

To the maximum extent permitted by law, I release Temple Aliyah, Temple Emunah, Temple Israel and Camp Ramah from liability resulting from any injury that my child suffers during the Retreat or in transit.

I give permission to Temple Aliyah, Temple Emunah, and Temple Israel  the right to obtain photographs and video of my child during the Retreat for publication within any of their internal publications or those of USY and USCJ.  

Transportation *
 Cost *
Code of Conduct

Please read and discuss with your child, then check both boxes below.

As a participant, I will:
- Respect the other participants and treat them as I would like to be treated.
- Show respect to the camp staff and cooperate with their instructions.
- Communicate in an appropriate manner, not using foul language or gestures, harsh words or tone of voice.
- Responsibly conduct my behavior and refrain from unwelcome teasing, bullying or other unkind behaviors.
- Refrain from causing bodily harm to others. This includes pushing, kicking, hitting, touching or fighting as this will not be tolerated at camp.
- Be respectful of the camp property and the property of others.
- Keep my cellphone and other communication devices off and in the bunk over the duration of the retreat.
-Will not use other electronics on Shabbat
- Not enter into another cabin other than my own.
- Not bring any tobacco products, alcohol, non-prescribed drugs or weapons to camp.
- Take full responsibility for my actions and understand that irresponsible behavior will result in disciplinary action. The staff will work with individual participants to modify inappropriate behaviors and will notify parents when necessary. The Directors may choose to dismiss a camper if inappropriate behavior does not improve.
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