Please send in a copy of your insurance card via email or mail. You can email Natalie Prior at [email protected] or send it in the mail to 27500 Shaker Boulveard, Pepper Pike, OH 44124, c/o Natalie Prior.

Medical History

EMERGENCY MEDICAL AUTHORIZATION

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

In the event of illness or injury, I do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgement of the attending physician, surgeon, or dentist and performed by or under supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services.

This authorization does not cover major surgery unless the 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.

Pertinent health information will be shared with appropriate synagogue staff only on a need-to-know basis

Facts concerning the child’s medical history including allergies, medications being taken, chronic illnesses or conditions, and any physical impairment to which a physician should be alerted: (Please use an additional sheet if necessary)

I MAKE THESE COMMITMENTS SO THAT I AND PARK SYNAGOGUE WILL GAIN THE MAXIMUM BENEFIT FROM MY PRESENCE AT THESE EVENTS, WHILE ALSO PROVIDING FOR A SAFE AND ENJOYABLE EXPERIENCE FOR ALL. THESE CONFIRMATION TRIP RULES APPLY FROM THE TIME I LEAVE HOME UNTIL MY RETURN.

1. I WILL OBSERVE KASHRUT AND SHABBAT IN ACCORDANCE WITH THE PRACTICES OF THE PARK SYNAGOGUE.

2. I REPRESENT MY CONGREGATION AND I WILL MAINTAIN PROPER BEHAVIOR WITH REGARD TO INTERPERSONAL RELATIONS (INCLUDING LANGUAGUE, SEX AND GENERAL BEHAVIOR) AND PERSONAL ATTIRE.

3. I WILL NOT BE INVOLVED IN ILLEGAL BEHAVIOR, OR CAUSE HARM TO MYSELF OR MY FELLOW CLASS MEMBERS (SUCH AS USE OR POSSESSION OF ALCOHOL, DRUGS OR ANY OTHER MIND ALTERING SUBSTANCE, FIREWORKS OR FIREARMS). I UNDERSTAND THAT MY ROOM OR SUITCASES MAY BE SEARCHED IF THERE IS SUSPICION OF POSSESSION AND/OR USE OF ANY OF THE ABOVE ILLEGAL SUBSTANCES OR MATERIALS.

4. I WILL NOT ENTER A ROOM OR AREA DESIGNATED FOR EXCLUSIVE USE BY MEMBERS OF THE OPPOSITE SEX.

5. I WILL ASSUME ALL RESPONSIBILITY FOR ANY DAMAGE TO PROPERTY THAT MAY BE CAUSED BY MY ACTIONS INTENTIONAL OR NOT, INCLUDING COSTS OR REPAIR OR REPLACEMENT OF SAID PROPERTY.

6. I WILL BE IN MY ASSIGNED ROOM AT CURFEW, AND WILL REMAIN THERE UNTIL THE NEXT SCHEDULED EVENT.

7. I WILL NOT ASSOCIATE WITH ANYONE NOT REGISTERED FOR THE EVENT, INCLUDING FRIENDS OR RELATIVES WITHOUT THE PRIOR CONSENT OF RABBI MARCUS.

8. I WILL LISTEN TO AND COOPERATE WITH STAFF AT ALL TIMES.

9. I UNDERSTAND THAT MY VIOLATING ANY OF THE ABOVE COMMITMENTS WILL RESULT IN DISCIPLINARY ACTION INCLUDING BEING SENT HOME IMMEDIATELY AT MY OR MY PARENTS OWN EXPENSE.

I HAVE READ THE ABOVE COMMITMENTS AND HAVE DISCUSSED THEM WITH MY CHILD. I ACCEPT ALL RESPONSIBILITY FOR MY CHILD’S ACTIONS, AND REALIZE THAT MY CHILD AND I ARE RESPONSIBLE FOR ALL EXPENSES INCURRED SHOULD MY CHILD BE SENT HOME, DUE TO ILLNESS OR ANY OTHER REASON DURING THESE EVENTS, OR FOR ANY DAMAGES THAT MAY OCCUR FROM MY CHILD’S ACTIONS. I ACKNOWLEDGE THE DISCIPLINARY RULES AND PROCEDURES OUTLINED ABOVE AND WILL ABIDE BY DECISIONS REACHED IN ACCORDANCE THEREWITH.

MY CHILD HAS MY PERMISSION TO GO ON THESE EDUCATIONAL FIELD TRIPS SPONSORED BY THE PARK SYNAGOGUE. I UNDERSTAND MY CHILD WILL TRAVEL BY BUS AND/OR PLANE AND WILL BE ACCOMPANIED BY STAFF. I EXPRESSLY RELEASE AND AGREE TO INDEMNIFY AND HOLD THE PARK SYNAGOGUE, ITS AGENTS, BOARD OF DIRECTORS, OFFICERS, EMPLOYEES, REPRESENTATIVES, AND LEGAL COUNSEL, FREE AND HARMLESS FROM ANY AND ALL LIABILITY, CHARGES, CLAIMS, COSTS AND EXPENSES OF EVERY KIND AND NATURE WHATSOEVER, INCLUDING REASONABLE ATTORNEY FEES, IN CONNECTION WITH THE ACCEPTANCE AND PARTICIPATION OF MY CHILD IN THE SCHEDULED ACTIVITY.