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Pop-Up Teen Retreat: Where's the Blessing?
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Retreat Details
This Pop Up Teen Retreat is for all 7th - 12th graders. It will be an awesome weekend at Camp Alonim full of fun, friends, games, ropes course, relaxation and more. Step away from your busy lives and experience a weekend in nature with your Jewish community.
Date:
Friday, November 30 - Sunday, December 2, 2018
Location:
Camp Alonim
(1101 Pepper Tree Ln, Simi Valley, CA 93064)
Pricing:
All Participants: $220
*Includes swag!
Helpful Links:
Frequently Asked Questions
Packing List
Teen Information
*
Teen's First Name:
*
Teen's Last Name:
*
Grade:
Please Select One
7th
8th
9th
10th
11th
12th
*
Birthdate:
*
Gender:
Please Select One
Male
Female
Other
Prefer not to answer
*
Teen's Email:
Teen's Cell (if applicable):
*
Name of School Teen Attends:
*
I am a:
Please Select One
Or Ami Congregant
Friend of an Or Ami Congregant
Member of Another Synagogue
Community Member (Unaffiliated)
If you are affiliated with another temple or Jewish organization, please write here:
*
Has your teen participated in other Or Ami youth programs besides this retreat?
Please Select One
Yes
No
*
How did you find out about the retreat?
Please Select One
I am an Or Ami congregant
From a friend
From a teacher, counselor, or youth advisor
Found it on social media
Found it somewhere else online
If you found out about the retreat from a friend or another organization, please list here:
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 Billing 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 to my/our teen participant in Congregation Or Ami's 7th-12th Grade 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 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. The hosting camp and Congregation Or Ami does not accept responsibility of loss, damage to, or theft of the teen’s property. The camp and Congregation Or Ami has blanket permission to transport campers off campgrounds for any and all trips, competitions and events. There is no fee reduction for late arrival or early departure from the retreat. Each retreat participant that needs medication during the retreat will bring to the bus pick up location this medication in a Ziplock bag in the original prescription bottle and written instructions for distribution. The Retreat Coordinators, Rabbi Julia Weisz and Elana Nemitoff, or any other Or Ami clergy member may expel a camper for behavior harmful or inappropriate to the retreat community. Please note that if a retreat participant is sent home early for behavior reasons, no refund will be given. I understand that part of the retreat 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 the camps’ 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 MEDICAL/LIABILITY TERMS ABOVE:
*
I/we understand that there is a $90 cancellation fee once my/our registration is processed. I/we also understand that if I need to cancel my/our teen's retreat registration less than 8 business days before the retreat, my/our 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 Pop-Up Teen 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.)
Please Select One
Yes, I would like to contribute
No, thank you.
*
A zip up hoodie sweatshirt will be provided as part of this weekend retreat. Please select your teen's shirt size.
Please Select One
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
Adult XXXL
Total Retreat Cost:
Thu, March 28 2024 18 Adar II 5784