3rd and 4th Grade Retreat

Please use this form to register and pay for our 3rd & 4th Grade Retreat at the Holden Arboretum on September 15, 2019. Drop off at the Temple at 9:30am and pickup at 4:00pm. All fields marked by an asterisk (*) require input.

* Please enter the number of students who will attend:

* Please type the full name of each student as well as their grade level as of September 2019.

(Ex: John Doe, 3rd Grade)

* I understand the following is expected of students attending this activity: To follow instructions given by the chaperone(s). Stay with our group the entire time unless given permission by the chaperone(s). Comply with all the rules of conduct explained at the beginning of the trip. In the event any of the above expectations are not upheld, I understand that I may be asked to come to the Arboretum to pick up my child. The Temple Tifereth Israel will provide supervision during Temple activities and outings. PLEASE TYPE YOUR FULL NAME INDICATING YOUR ACKNOWLEDGEMENT OF THIS STATEMENT.

* I, the parent/guardian of the above student do agree to indemnify and hold harmless The Temple Tifereth Israel for accidents, injuries and/or losses that occur on Temple outings or activities unless such accidents, injuries or losses are a direct result of gross negligence on the part of the Temple Tifereth Israel or its staff. I/We the undersigned parent/guardian hereby consent to his/her participation in the 3rd and 4th Grade Retreat, September 15, 2019 including travel between the Holden Aboretum and The Temple. PLEASE TYPE YOUR FULL NAME INDICATING YOUR ACKNOWLEDGEMENT OF THIS STATEMENT.

* MEDICAL EMERGENCY CONSENT In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by a licensed physician or dentist and the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

	Yes
	No - (If you select no please complete the box below)

* REFUSAL TO GRANT CONSENT I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the Trip Supervisor to take the following action:

A response is required. Please type "n/a" if you chose "Yes" above.

Emergency Contact Information

* Emergency Contact #1

* Emergency Contact #1 Relationship to Child

* Emergency Contact #1 Email Address

* Emergency Contact #1 Cell Phone

* Emergency Contact #1 Home Phone

* Emergency Contact #1 Work Phone

* Emergency Contact #2

* Emergency Contact #2 Relationship to Child

* Emergency Contact #2 Email Address

* Emergency Contact #2 Cell Phone

* Emergency Contact #2 Home Phone

* Emergency Contact #2 Work Phone

* Family Physician Name and Phone Number

* Date of last tetanus shot/booster

* IMPORTANT Please indicate any medical information, behavioral issues, and/or special needs your child may have of which you would like the supervisors to be aware – such as (but not limited to) asthma, allergies to bug bites (bee stings), and/or food allergies. If there are no issues, please type "n/a".

* Medication(s) to be taken on this trip should be listed and described below and also labeled with: - The name of child - The name of medication - The reason for taking the medication - The dosage and directions for administering (including time for dispensing), and what should or should not be taken with the medication, as well as any other pertinent information. Unless indicated otherwise, medication will be held by an adult supervisor. Please duplicate this information on the packaging in which you choose to send the medication. If there are no medications, please type "n/a".

An asterisk (*) indicates a require field.

I would like to reserve and pay later.

Leave as "No" if you are paying online now. Change to "Yes" if you are paying by check or cash the day of the event. Please be aware that by reserving now you will be responsible for payment.