Or Ami Does Disneyland 2019 (7th Grade)

Trip Details

A brand new trip just for 7th graders!

Teens will spend the night at Or Ami, then get up early and enjoy a full day at Disneyland.

Friday, August 30 - Saturday, August 31

Drop off at Or Ami at 7:00 pm on Friday night.
Pick up at Or Ami at 10:00 pm on Saturday night.

Pricing:
Early Bird (by July 28): $300
Regular (after July 28): $325

*Trip cost is non-refundable

Teen Information

* Teen's First Name:

* Teen's Last Name:

* Teen's Email:

* Teen's Cell:

* Birthdate:

* Teen's T-shirt Size:

* I am a:

Parent/Guardian Information

Parent/Guardian #1

* First Name:

* Last Name:

* Cell Phone:

* Email:

Parent/Guardian #2

First Name:

Last Name:

Cell Phone:

Email:

Teen Emergency/Medical Information

* Emergency Contact Full Name:

* Emergency Contact Phone:

* Contact's Relationship to Teen:

* Physician's Name:

* Physician's Phone:

* Medical Insurance Company:

* Insurance Policy Number:

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

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

Please list any dietary restrictions your teen may have including, but not limited to, vegetarian and gluten free:

* I/we hereby give permission for my/our teen to participate in Congregation Or Ami's 7th Grade Overnight & Disneyland Trip, and do release Congregation Or Ami, its Rabbis, cantor, educators, board members, leaders, and its representatives from all liability arising out of my/our teen's participation in that activity. 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 teen, 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 teen’s property. Congregation Or Ami has blanket permission to transport participants offsite for any and all trips and events. Each participant that needs medication during the overnight and/or trip will bring to the drop off location this medication in a Ziplock bag in the original prescription bottle and written instructions for distribution. The Trip Coordinator, Rabbi Julia, or any other Or Ami clergy member may expel a participant for behavior harmful or inappropriate to the trip community. Please note that if a trip participant is sent home early for behavior reasons, no refund will be given. I understand that part of the trip experience involves activities and group interactions that may be new to my/our teen, and that the activities may come with uncertainties beyond what my/our teen is 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 my/our teen I realize that no environment is risk free, and so I have instructed my/our teen on the importance of abiding by Or Ami’s rules, and my/our teen 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 TERMS ABOVE (WRITE FULL NAME):

* I/we understand that my/our trip registration fee is non-refundable. Please put your full name in the box to acknowledge.

Please let us know if you would like to help underwrite a portion of the trip 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 Trip Registration Cost:

Sat, July 20 2019 17 Tammuz 5779