Registration - JewishCenter.info

Name*

FirstLast

Gender*

MaleFemale

Hebrew Name*

Mother's Hebrew Name*

Birth Date*

MonthDayYear

Grade currently in*

School Attending*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell*

E-mail*

I would like to receive news and updates by email

Comments

Parents

Parents Marital Status

Dad's Name

FirstLast

Dad email

Dad Cell

Mom's name

FirstLast

Mom email

Mom Cell

Reference

A Rabbi or teacher who knows you well and will be able to a character reference for you.

Reference's Name*

FirstLast

Reference's Email*

Reference's Phone Number*

Friend Requests

You may make up to three friend requests, of whom you would like to room with when possible. We will try our hardest to honour at least one of your requests.

Billing Info

Application deposit is due upon form submission. Your card will only be charged once your child is accepted. It will then be charged an initial deposit of $250 which will secure your child’s place in camp. This amount will come off the balance of the camp fees. Camp pricing is in USD. Full payment is required before camp begins.

Price

Before December 1 - $2999.00Before January 1 -$3499.00Before May 1 - $3999.00After May 1: $4,499.00 (subject to availability)

$250 Deposit due upon submission*

Pay by chequePay by credit card

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Total

$250.00

Feedback

How did you hear about Brazil Trip?

Code of Conduct

No smoking is allowed. There is to be no possession or use of any narcotics, marijuana, other illegal drugs or prescription drugs not specifically prescribed for the user. There will be no possession or consumption of any alcoholic beverages. I will not shoplift or engage in any other type of illegal behaviour. Any participant caught in possession of/or using alcohol or illegal drugs, will immediately be sent home at his/her parent’s expense. Participants are expected to maintain proper decorum and attitude during the entire program. Disruptive behaviour (including, among other things, inappropriate sexual innuendo) will not be tolerated in any way shape or form. No participant may leave the facility or group except at those times specified by the schedule. Each participant is expected to conduct him/herself appropriately as a Jew (including through the observance of Kashrut), in accordance with applicable standards of the trip organizers. The (Jewish Teen Network) JTN Director & Chaperones, reserves the right to enforce other rules relating to the integrity of JTN Youth Programs and/or the health, safety or welfare of it’s participants. The JTN Director & Chaperones reserves the right to search the room and belongings of any participant if they believe that such a search is necessary to secure the health, safety and/or welfare of the program and or its participants. I have read these rules and understand them fully. I certify that I will adhere to this Code and will conduct myself in a manner reflecting credit upon my peers, my community and myself. I understand that any violation of this code of conduct may result in my being sent home at my parents’ expense. The JTN Director & Chaperones have the sole discretion to send a participant home.I, the parent/guardian of, a minor, who will be participating in the Jewish Teen Network Brazil Trip, do hereby certify that I have read the Code of Conduct set forth above. I do hereby agree that if my child who has signed the above Rules of Conduct fails to adhere to the Code, then in such event those persons in charge of the program may send my child home at my expense. I understand that The JTN Director & Chaperones have the sole discretion to send my child home.

PLEASE READ AND SIGN THIS DISCLAIMER OF LIABILITY*

I have adequate medical coverage and insurance and give my child permission to attend The Jewish Teen Network Brazil Trip and we (or I) agree to indemnify Jewish Teen Network, and all its officers, coaches and members for any claim which may hereafter be presented by our (or my) child as a result of any such injuries.

Health Emergency

Emergency Contact**

FirstLast

Emergency Cell**

Allergies, health or medical conditions

Statement and Emergency Authorization

I (the parent or legal guardian) of the applicant state that he/she is in good/normal health, has no physical or mental handicaps that would interfere with full participation in the program and has my permission to engage in all available activities except as noted under Restrictions or Modifications above.

I have been made aware of the fact that the events in which the likeness of my child is participating may be photographed by either amateur or professional photographers, and that the photographs may be used for purposes of reporting on the event, future publications or promotional material use as Jewish Teen Network may determine. It is my understanding that by signing this document I consent to the use of the pictures just referred to for any purpose whatsoever.

In case of a medical emergency, accident or health problem where immediate treatment is deemed necessary, every effort will be made to expeditiously contact the parent(s) or guardian(s) of the participant, or the emergency contact person listed above. In the event I cannot be reached, I hereby give permission to the physician selected by The JTN Director & Chaperones, or his/her designee, to hospitalize, secure proper and ongoing treatment and to order injection, anesthesia, or surgery for my child as named above.

I fully agree to assume any financial responsibilities that may result from the aforementioned decision taken by the aforementioned individuals. I am aware that this form may be photocopied for use by medical caregivers.

Parent / Guardian*

FirstLast

Date*

Agreement*

I read and agree to all the above