Or Ami Congregant Early Bird Price: $220 (through January 5)
Guests Early Bird Price: $240 (through January 5)
Or Ami Congregant Regular Price: $240 (after January 5)
Guests Regular Price: $250 (after January 5)
**All prices include swag

Teen's First and Last Name

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* 1. Teen's First and Last Name

I am a

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* 2. I am a

If not an Or Ami congregant, how did you hear about the retreat? If you heard about the retreat from an Or Ami congregant, please list the congregant's name here. 
If you heard about this retreat from another organization, please list that organization here.

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* 3. If not an Or Ami congregant, how did you hear about the retreat? If you heard about the retreat from an Or Ami congregant, please list the congregant's name here. 
If you heard about this retreat from another organization, please list that organization here.

Grade

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* 4. Grade

Birthdate month/day/year

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* 5. Birthdate month/day/year

Parent/Guardian #1 Name

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* 6. Parent/Guardian #1 Name

Parent/Guardian #1 Cell Number

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* 7. Parent/Guardian #1 Cell Number

Parent/Guardian #1 Email

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* 8. Parent/Guardian #1 Email

Parent/Guardian #2 Name

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* 9. Parent/Guardian #2 Name

Parent/Guardian #2 Cell Number

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* 10. Parent/Guardian #2 Cell Number

Parent/Guardian #2 Email

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* 11. Parent/Guardian #2 Email

Medical information - Please indicate any allergies (including food) or specific medical concerns

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* 12. Medical information - Please indicate any allergies (including food) or specific medical concerns

Medical Insurance Company

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* 13. Medical Insurance Company

Insurance Billing Policy Number

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* 14. Insurance Billing Policy Number

Physician's Phone Number

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* 15. Physician's Phone Number

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

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* 16. Please list any medications your child is taking (medication name/dosage/frequency)

Emergency Contact

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* 17. Emergency Contact

Emergency Contact Phone Number

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* 18. Emergency Contact Phone Number

Contact's Relationship to Child

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* 19. Contact's Relationship to Child

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

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* 20. Please list any dietary restrictions your child may have including, but not limited to, vegetarian and gluten free

Please indicate how you will be paying for the retreat.

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* 21. Please indicate how you will be paying for the retreat.

Waiver Form:

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 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, 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 theftof the child'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 Julie Bressler, 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 FORM ABOVE: *

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* 22. Waiver Form:

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 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, 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 theftof the child'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 Julie Bressler, 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 FORM ABOVE: *

I would like to help underwrite a portion of the Triple T Retreat and would like someone from the office to call me. (Your contribution will enable us to provide more scholarship funds for children in need.)

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* 23. I would like to help underwrite a portion of the Triple T Retreat and would like someone from the office to call me. (Your contribution will enable us to provide more scholarship funds for children in need.)

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 child'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.

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* 24. 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 child'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.

A zip up hoodie sweatshirt will be provided as part of this weekend retreat. Please check the box of sizing you would like for your child.

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* 25. A zip up hoodie sweatshirt will be provided as part of this weekend retreat. Please check the box of sizing you would like for your child.

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