Kesher 2021 Off-Site Liability Form

* Student Full Name:

* Your Email:

* I/we hereby give permission to my/our child to participate in Congregation Or Ami educational programs away from Congregation Or Ami’s premises, and do release Congregation Or Ami, its Rabbis, cantor, educators, board members. leaders, and its representatives from all liability arising out of my/our child’s participation in such off-site programs. In addition, I, the undersigned parent/guardian of the above-named teen do further assign Congregation Or Ami and its authorized representatives as agents for the undersigned to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care for the above-mentioned child, which is to be rendered under the general or specific supervision of any licensed physician or dentist under the provision of the California Medicine Practice Act and Dental Practice Act or the staff of a licensed hospital, whether such diagnosis, examination or treatment is rendered at the office of said physician or such hospital. It is understood that the authorization is given in advance of any specific examination, diagnosis, treatment or hospital care being required, and is given to provide authority and power of our above named agents to give specific consent to any and all such examinations, diagnosis, treatment or hospital care with the aforementioned physician in the exercise of his/her best judgement may deem advisable. THE AUTHORIZED IS GIVEN PURSUANT OF SECTION 25.8 OF THE CIVIL CODE CALIFORNIA. Congregation Or Ami does not accept responsibility of loss, damage to, or theft of the child’s property. I am/we are aware that there are risks inherent to my/our child’s participation in these off-site programs, and I am/we are assuming them on behalf of my/our child I/we realize that no environment is risk free, and so I/we have instructed my/our child on the importance of abiding by Congregation Or Ami’s rules, and my/our child and I both agree that he or she is familiar with these rules and will obey them. I HAVE READ AND FULLY AGREE TO THE MEDICAL/LIABILITY TERMS ABOVE

My typed name above serves as my signature.

Sat, April 20 2024
12 Nisan 5784

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Sat, April 20 2024 12 Nisan 5784