Youth Group Event Emergency / Liability Form

We're excited your teen is participating in a youth group event at Or Ami!

Please fill out the following emergency and liability form.

* Youth Group Event Name:

* Date of Event

* Teen Participant Full Name:

Additional Teen Participant Full Name:

* Teen's Doctor:

* Doctor's Phone:

* Medical Insurance Provider:

* Name of Subscriber:

* Insurance Policy Number:

Please list any medical conditions, allergies, etc. of teen(s):

* Parent Full Name:

* Parent Cell Phone:

* Parent Email:

* Additional Emergency Contact - Full Name:

* Emergency Contact Cell Phone:

* I/we hereby give permission for my/our teen to participate in Congregation Or Ami's Youth Group Event, and agree to release and hold harmless Congregation Or Ami, its Rabbis, cantor, educators, staff, board members, leaders, and its representatives from all costs, damages, claims, causes of action, losses and liability arising out of or related to my/our teen’s participation in, or transportation to/from/during, this activity. Moreover, I/we hereby assume all risks inherent in or associated with my/our teen’s participation in, or transportation to/from/during, this activity. In the event of an emergency or the sudden illness of my/our teen occurring when I/we cannot be reached, I/we also give my/our consent for my/our above-named teen to be treated by such emergency medical personnel, doctors and/or hospitals, as are selected by Congregation Or Ami. I/we understand that in the event of such emergency, Congregation Or Ami will make reasonable efforts to consult with the physician or medical group named above, but the nature of the emergency may require treatment be undertaken before such consultation is possible. Congregation Or Ami does not accept responsibility of loss, damage to, or theft of the teen’s property. I HAVE READ AND FULLY AGREE TO THE TERMS ABOVE.

My typed name above serves as my signature.

* Date

Fri, April 26 2024
18 Nisan 5784

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Fri, April 26 2024 18 Nisan 5784