Park Synagogue Confirmation Class 2025-26

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 the following commitments to help create a meaningful, safe, and respectful experience for everyone involved in the Confirmation program. These expectations apply from the time I leave home until I return.

1. I will observe Shabbat and kashrut in accordance with the practices of Park Synagogue throughout all program events and trips.

2. I understand that I represent Park Synagogue, and I will demonstrate respect and responsibility in my language, actions, and appearance. I will treat all people with kindness, dignity, and inclusion.

3. I will not engage in illegal or harmful behavior, including the use or possession of alcohol, drugs, or other mind-altering substances, fireworks, or weapons. I understand that, if there is reasonable concern about possession or use of these items, my belongings may be searched.

4. I will respect everyone’s personal boundaries and private spaces, including only entering sleeping rooms and areas I am assigned to. This applies regardless of gender identity or expression.

5. I will take responsibility for any damage I may cause—whether accidental or intentional—and understand I (or my family) may be held financially responsible for repair or replacement costs.

6. I will be in my assigned room at curfew and remain there until the next scheduled activity.

7. I will not meet with individuals who are not part of the Confirmation program, including friends or family, without prior permission from Rabbi Marcus or staff.

8. I will listen to and cooperate with all program staff to help ensure a positive and safe experience for everyone.

9. I understand that serious violations of these commitments may result in disciplinary action, including being sent home early at my or my family's 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.