NCSY City/Valley Shabbaton  2014
Starting: Friday, October 31st, 2014
Ending:  Sunday, November 2nd, 2014

City Chapter/Valley Shabbaton

City Registration is Friday at 1:00pm at the NCSY Los Angeles office (9831 W. Pico Blvd. 90035) 
Valley Registration at 2:00pm Chabad of Tarzana 18181 Burbank Blvd Tarzana Ca


Pick Up: Sunday, 12:30pm
Valley location: Chabad of Tarzana 18181 Burbank Blvd Tarzana Ca

Pick Up: Sunday, 1:15pm
City Location: NCSY Office 9831 West Pico Blvd. LA, CA 90035

Member's Rate: $130
Regular Rate: $140

Membership Fee: $36

NO REFUNDS AFTER 10/20/2014

Contact Information:
Regional Office: (310) 229 - 9000 ext. 209
FAX (310) 229 - 9008

NO APPLICATION CAN BE PROCESSED WITHOUT PAYMENT!
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Contact Information
First Name *
Last Name *
Email Address *
Cell Phone Number *
Address *
City *
State *
Zip *
Home Number *
Applicant Information
Chapter *
School *
If your school is not listed, choose "Other" and enter your school below.
Other School
Grad year *
Birthday Month *
Birthday Date *
Birthday Year *
Gender *
NCSY Member *
Emergency Information
Dad First Name *
Dad Last Name *
Dad Cell Phone *
Dad Email *
Mom's First Name *
Mom's Last Name *
Mom's Cell *
Mom's Emall *
Emergency Contact Name *
Emergency Contact Relationship *
What is the contact's relationship to the NCSYer?
Emergency Contact Phone Number *
Notes
Allergy Info, Medical Info, Any Other Important Information For Our Office.
Rooming, Meal and Preference Information
Room Request 1 *
Room Request 2 *
Room Request 3
Room Request #4
How Did You Hear About The Shabbaton? *
Would you like to daven? Can you read the Torah? Or give a Dvar Torah?
Payment Information
Check (Please Mail to Address Above) *
Credit Card Number
Expiration Month
Expiration Year
Name on the Card
Billing Address
Applicable Rate *
Would You Like To Sign Up To Be A Member *
Annual Membership Fee  $36
Would you like to donate to NCSY to help support our scholarship fund?
Please indicate amount below, donations are fully tax deductible.
Total *
(Add Applicable Rate, Membership Fee, Donation)
Waiver and Agreement
Guardian Waiver *
As per the E-SIGN bill approved by congress and signed into law, your Digital Signature below is binding as your signature on a paper contract: As legal guardian, I hereby * grant permission for my child to attend the NCSY sponsored event at the place and on the date/s stipulated in the accompanying application. * My child and I are familiar with the NCSY standards of conduct (See www.NCSY.org/standards) and we understand that if my child violates the standards or does not exercise good judgment in his/her behavior at the event, * NCSY has the right to dismiss my child without refund and discuss any disciplinary problems experienced at the event with the administration of my child’s school at NCSY’s discretion. * I am aware that I will be held responsible for any damage to public or private property that NCSY states my child caused and agree to fully reimburse all parties involved. * I further acknowledge that NCSY, at its discretion, may request that my child voluntarily undertake a non-physician administered test for drugs and alcohol, and that refusal to take such a test voluntarily or a positive result obtained from such a test will also serve as grounds for immediate dismissal. * In the event of my child’s dismissal, I acknowledge that it is my responsibility to secure immediate transportation home for my child at my sole expense. In the event I am unable to secure immediate transportation, I grant permission for NCSY to arrange transportation at my sole expense. I consent to this transportation even if unchaperoned and I agree to fully reimburse NCSY for any expenses incurred within one week of the event. * Concerning my child’s medical needs, NCSY may provide over-the-counter medication (Tylenol, Advil, Kaopectate, Benadryl, etc.) as deemed necessary. - I understand that this does not require NCSY to provide medical treatment. - I have advised NCSY of any over the counter medications which may not be administered to my child. * I certify that my child is fully capable of participating in all activities associated with this event, and that my child has no unreported physical or mental disabilities or infirmities that would restrict full participation. * I understand that in case of emergency, every effort will be made to contact me or my emergency contact. If we cannot be reached, I give permission to the physician or EMT selected by NCSY to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child. - I agree to reimburse immediately and/or accept primary financial responsibility for the total cost of all medical care provided to my child. * I acknowledge and am willing to assume and accept any risks associated with my child’s participation in any aspect of this event, and I agree that the terms of this waiver will likewise bind me, my child, my heirs, legal representatives, and assignees. * I release and will defend, indemnify, and hold harmless the Orthodox Union, NCSY, its directors, owners, agents, employees, and volunteers (“releasees”) from every claim and any liability that I or my child may allege against the releasees (including reasonable legal fees and costs) as a direct or indirect result of harm to my child while s/he is in the care of NCSY. * I grant permission for NCSY to use in their promotional materials any photograph or video images of my child which may be taken at the event and * I accept that NCSY will not be responsible for any “lost and found” items that remain unclaimed after 30 days. * I accept that NCSY reserves the right to, and grant permission to NCSY, its employees, volunteers and agents to search my child's belongings and person if it is deemed neccesary. A parent or legal or guardian must enter his/her digital signature below:
Participant Waiver *
As per the E-SIGN bill approved by congress and signed into law, your Digital Signature below is binding as your signature on a paper contract: In registering for this NCSY event, I herby agree to adhere to the program, observe the religious code set for the event and the NCSY Standard of Conduct (See www.NCSY.org/standards) and conduct myself in a manner reflecting credit upon my congregation and community. The Participant must enter his/her digital signature below.
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