Registration & Permission Form for Loon Mountain, January 12-13, 2019
I give permission for my child to participate fully in the Loon Mountain Trip on January 12-13, 2019. *
Type your child's name
Your answer
*
Type your name to sign
Your answer
I hereby empower JTI staff and 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 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. *
I agree to grant to JTI and its authorized representatives permission to record on photography film and/or video, pictures of my child's participation. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed materials used to promote JTI, and further that such use shall be without payment of fees, royalties, special credit or other compensation. *
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
Age during event
Your answer
Graduation Year *
School Name *
Your answer
School Type *
Synagogue Affiliation
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 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
Please indicate what you want included in your trip to Loon. *
Required
Signature of Parent or Guardian *
Type your name below to sign
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 payment. You can pay using PayPal through our website or you can mail a check to:

Jewish Teen Initiative
6 Community Road
Marblehead, MA 01945

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