Mensch-ify Family Retreat 2019

Retreat Details

When: Friday, September 20 - Sunday, September 22, 2019

Where: Camp Alonim (1101 Peppertree Lane, Brandeis, CA 93064)

What: A retreat for the whole family! We'll celebrate Shabbat together and enjoy a weekend of hiking, sports, arts, relaxing, and connecting with friends and clergy.

Cost:

Adults and children age 6 and up: $75 per person
Children age 2 - 5: $50 per person
Children under age 2: free

Cost includes family lodging, all meals (Friday dinner through Sunday breakfast), weekend activities, and commemorative swag!

Registration

* Please select number of people in your family attending:

Adults and children age 6 and up ($75/person)

Children age 2 - 5 ($50/person)

Children under 2 (free)

Youth Information

Please fill out the following information for all children attending the retreat. (Click plus sign to add information for multiple children.)

* First Name:

* Last Name:

* Grade:

* Birthdate

T-Shirt Size:

Please indicate any allergies (including food) or specific medical concerns:

Please list any medications your child is taking (medication name/dosage/frequency):

Please list any dietary restrictions (such as vegetarian, gluten free, etc.):

CLICK TO ADD MORE CHILDREN

* First Name:

* Last Name:

* Grade:

* Birthdate

* T-Shirt Size:

Please indicate any allergies (including food) or specific medical concerns:

Please list any medications your child is taking (medication name/dosage/frequency):

Please list any dietary restrictions (including vegetarian, etc.):

Parent/Guardian Information

Please fill out the following information for all parents attending the retreat.

Parent/Guardian #1

* First Name:

* Last Name:

* Cell Phone:

* Email:

T-Shirt Size:

Please list any dietary restrictions (such as vegetarian, gluten free, etc.):

Parent/Guardian #2

First Name:

Last Name:

Cell Phone:

Email:

T-Shirt Size:

Please list any dietary restrictions (such as vegetarian, gluten free, etc.):

Family Emergency & Medical Information

* Emergency Contact's Full Name:

* Emergency Contact's Phone:

* Contact's Relationship to Child:

* Children's Physician's Name:

* Children's Physician's Phone Number:

* Medical Insurance Company:

* Insurance Policy Number:

* I/we hereby give permission to my/our child to participate in Congregation Or Ami's Mensch-ify Retreat, 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, and my/our participation, in that activity. In addition, I/we, the undersigned parent(s)/guardian(s) of the above-named child, 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, or for me/us if I/we am/are incapacitated, 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. The hosting camp and Congregation Or Ami does not accept responsibility of loss, damage to, or theft of the child’s or my/our property. The camp and Congregation Or Ami has blanket permission to transport my/our child off campgrounds for any and all trips, competitions and events. I/we understand that if my/our child needs medication during the retreat, I/we will be solely responsible to store and administer such medication to my/our child. I/we understand that if I/we do not want such responsibility, I/we will bring to the drop-off site any such medication in a Ziplock bag in the original prescription bottle and written instructions for distribution. The Retreat Coordinator, Rabbi Julia Weisz, or any other Or Ami clergy member may expel me/us, or my/our child for behavior harmful or inappropriate to the retreat community. I/we understand and agree that if my/our child or I/we am/are expelled early for behavior reasons, no refund will be given. I/we understand and agree that part of the retreat experience involves activities and group interactions that may be new to me/us and to my/our child, and that the activities may come with uncertainties beyond what I/we or my/our child is/are used to dealing with at home. I am/we are aware that of these risks, and I am/we are assuming them on behalf of myself/ourselves and my/our child, and I/we realize that no environment is risk free, and so I/we understand, and I/we have instructed my/our child on, the importance of abiding by the camp’s rules, and I/we and my/our child both agree that we are familiar with these rules and will obey them. I/WE HAVE READ AND FULLY AGREE TO THE MEDICAL/LIABILITY TERMS ABOVE (please write full name(s) to acknowledge):

* I/we understand that there is a $50 cancellation fee once my/our registration is processed. I/we also understand that if I need to cancel my/our retreat registration less than 8 business days before the retreat, my/our registration fee is non-refundable. Please write your full name in the box to acknowledge.

Please let us know if you would like to help underwrite a portion of the Mensch-ify Family Retreat and would like someone from the office to call you. (Your contribution will enable us to provide more scholarship funds for children in need.)

Total Retreat Cost:

Fri, November 29 2024 28 Cheshvan 5785

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