Teen High Holiday Offsite Services Registration Form

Welcome to the VBS Youth Department, the central place for all children and teens of our community.

Below, please find the sign up form for our Teen High Holiday Program (Grades 7-12): Holy ViBeS!

Program Description: During the morning services of Rosh Hashanah Day 1 and Yom Kippur, teens will have the opportunity to go OFF-SITE and participate in their own "intentional" HIGH HOLIDAY "experience," Camp ViBeS style!

The Youth Department will lead various interactive, spiritual and thought provoking adventures through the wilderness of the Santa Monica Mountains! *details revealed prior to Chagim

*Bus transportation is provided.

Choose from:

September 26 - Rosh Hashanah, Day 1 - Morning Only: 9am-12:30pm
October 5 - Yom Kippur - Morning Only: 9am-12:30pm

For any Youth Department questions, please contact Director of Youth Engagement, Camryn Kruger at (818) 530-4025 or ckruger@vbs.org.

* Parent/Guardian 1 Last Name

* Parent/Guardian 1 First Name

Relationship to child

* Parent/Guardian 1 Email

* Parent/Guardian 1 Phone

Parent/Guardian 2 Last Name

Parent/Guardian 2 First Name

Relationship to child

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

* How many youths are you enrolling?

Youth 1 Information

* First Name

* Last Name

Phone

Grade Fall 2022

Date of Birth

Gender

MaleFemaleNon-Binary

Primary School

REGISTRATION

Choose the program your teen will attend Check all that apply

Rosh Hashanah, Day 1: September 26, 9am-12:30pmYom Kippur: October 5, 9am-12:30pm

MEDICAL HISTORY

Please list all medications currently being taken:

Medical/Psychological Conditions:

Allergies to Medication:

Medical Insurance:

ID#:

Doctor:

Phone:

Date of Last Tetanus Shot:

* PARENT/GUARDIAN 1: Please type name below to agree

Date:

* PARTICIPANT: Please type name below to agree

Date:

Youth 2 Information

* First Name

* Last Name

Phone

Grade Fall 2022

Date of Birth

Gender

MaleFemaleNon-Binary

Primary School

REGISTRATION

Select the program your teen will attend. Check all that apply

Rosh Hashanah, Day 1: September 26, 9am-12:30pmYom Kippur: October 5, 9am-12:30pm

MEDICAL HISTORY

Please list all medications currently being taken:

Medical/Psychological Conditions:

Allergies to Medication:

Medical Insurance:

ID#:

Doctor:

Phone:

Date of Last Tetanus Shot:

* PARENT/GUARDIAN 1: Please type name below to agree

Date:

* PARTICIPANT: Please type name below to agree

Date:

Youth 3 Information

* First Name

* Last Name

Phone

Grade Fall 2022

Date of Birth

Gender

MaleFemaleNon-Binary

Primary School

ENROLLMENT

Select the program your teen is attending. Check all that apply

Rosh Hashanah, Day 1: September 26, 9am-12:30pmYom Kippur: October 5, 9am-12:30pm

MEDICAL HISTORY

Please list all medications currently being taken:

Medical/Psychological Conditions:

Allergies to Medication:

Medical Insurance:

ID#:

Doctor:

Phone:

Date of Last Tetanus Shot:

* PARENT/GUARDIAN 1: Please type name below to agree

Date:

* PARTICIPANT: Please type name below to agree

Date:

COVID-19 PANDEMIC CONSENT AND REGISTRATION

To Attend Services/Programs at Valley Beth Shalom (the “Consent”)

As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19 at any time or in any place. Valley Beth Shalom (“VBS”) has established protocols for services and will be diligently following local, state, federal and CDC laws and guidelines for reopening – including disinfecting, social distancing and personal protection. You could become exposed to COVID-19 at any time or place despite VBS’ careful attention and policies. In addition, despite VBS’ efforts, it is impossible to completely assure you that all other attendees will always follow these guidelines in perfect compliance at all times and it is required to complete and sign this Consent in order to attend services at VBS.

I knowingly and willingly consent to sending my family and attending worship services/programs during the COVID-19 Pandemic at VBS despite the risks outlined above and below.

PARENT/GUARDIAN 1: Please type name below to agree

Date:

ENROLLMENT AND RESPONSIBILITIES AGREEMENT

By signing this Enrollment Agreement I/we acknowledge and agree to the following:

I/We understand that Valley Beth Shalom will enforce a behavior management policy. I/we understand that serious infractions such as, but not limited to, stealing, fighting, possession of contraband on campus (weapons, drugs or alcohol), willful destruction of school property, and/or bullying (including verbal and/or sexual harassment) may result in an immediate removal from class and may result in discipline up to and including dismissal with no refund of payment.

I/We have read, understand and agree to be bound by this enrollment agreement for myself/ourselves and on behalf of my/our child/children.

* PARENT/GUARDIAN 1: Please type name below to agree

Date:

PARENT/GUARDIAN 2: Please type name below to agree

Date:

TRANSPORTATION RELEASE

I/We give permission and consent to VBS and its employees and agents to take my/our child/children on field trips as part of the normal curriculum and, to the extent possible, release Valley Beth Shalom and its employees and agents from any liability for personal injury to my/our child/children or property damage, except for injuries resulting from gross negligence of Valley Beth Shalom or their employees or agents.

* PARENT/GUARDIAN 1: Please type name below to agree

Date:

PARENT/GUARDIAN 2: Please type name below to agree

Date:

MEDICAL EMERGENCY RELEASE

In the event of a medical emergency, in accordance with the Valley Beth Shalom emergency procedure, I/we, the undersigned parent(s) or legal guardian(s), do hereby release the appropriate personnel of Valley Beth Shalom to either administer first aid OR release the child/children to an emergency Hospital, urgent care facility or disaster center, for further treatment, as they deem necessary. Furthermore, I/we authorize appropriate care to be rendered by a duly licensed physician, nurse, surgeon, dentist and/or medical professional. This care may be given under whatever conditions are necessary to preserve the health and safety of the child/children. I/we further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, VBS personnel will try, but are not required, to communicate with me/us prior to such treatment.

* PARENT/GUARDIAN 1: Please type name below to agree

Date:

PARENT/GUARDIAN 2: Please type name below to agree

Date:

PHOTO/AUDIO/VIDEO/WEBSITE RELEASE

I/We give permission for photographs, video or audio recordings to be taken of my/our child/children to be used for public relations purposes and the promotion of Valley Beth Shalom on its printed materials, posters, flyers and websites.

* PARENT/GUARDIAN 1: Please type name below to agree

Date:

PARENT/GUARDIAN 2: Please type name below to agree

Date:

PICK UP RELEASE

In accordance with the VBS emergency procedures, you are authorized to release my/our child/children to the following people (other than the parents/guardians):

Number of people allowed to pick up

Pickup Name One

Pickup Phone One

Pickup Name Two

Pickup Phone Two

Pickup Name Three

Pickup Phone Three

In case of Emergency, please list one in-state and one out-of-state contact:

In-State Contact

In-State Phone

Out-of-State Contact

Out-of-State Phone

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