Bi-Temple Shul-In Registration
This event is on May 20-21, 2017 from 3:00pm to 9:00am. Please Register by May 18th.
Participant's Name
Your answer
Email
Your answer
Phone Number
Your answer
Participant's Youth Group
Parent/Guardian Authorization and Medical Release Form
My child has permission to attend Bi Temple Shul-In from May 20-21, 2017. I agree not to hold CBI, CKA, and/or its agents liable for any accident, loss or theft that may occur during the course of this event. I give permission to the adult staff to transport my child to and from an off-site location during the course of this event for the purpose of the event. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the adult staff to hospitalize, secure proper treatment for and order injections, anesthesia or surgery for my child as named above. I recognize that I will be responsible for any costs incurred for this treatment.
Parent/ Guardian Signature
Your answer
Medical Information or Dietary Needs
Your answer
Emergency Contact Name
Your answer
Emergency Contact's Relationship
Your answer
Emergency Contact's Phone Number
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms