7th & 8th Grade Retreat

Friday, January 10, 2025 • 10 Tevet 5785

5:00 PM - 2:00 PM Next DayTemple Shir Shalom & Walled Lake Outdoor Education Center

Register

* Student's First Name:

* Student's Last Name:

* Student's Grade:

* Will your child be attending the retreat?

* Student's Birthdate:

* Parent/Guardian First Name:

* Parent/Guardian Last Name:

* Parent/Guardian Email:

* Parent/Guardian Cell Phone:

Please use xxx-xxx-xxxx format.

January 10-11, 2025 Madrichim Retreat

Please complete the following information to register your child to travel to the Walled Lake Outdoor Education Center January 10-11.

I give my child permission to go to the Walled Lake Outdoor Education Center (WLOEC) with Temple Shir Shalom.

I understand that transportation will be provided by school bus between Temple and the (WLOEC). In case of an emergency and I am unable to be reached, I give Temple Shir Shalom the authorization to act on my behalf for the care or treatment of my son/daughter.

* Street Address:

* City:

* State:

* Zip Code:

Home Phone:

Lnadline only. Please use xxx-xxx-xxxx format.

Second Parent/Guardian First Name:

Second Parent/Guardian Last Name:

Second Parent/Guardian Cell Phone:

Please use xxx-xxx-xxxx format.

If the second parent/guardian lives in a different household, please provide address information. If both parents reside in the same house, please leave the information blank.

Second Parent/Guardian Street Address:

Second Parent/Guardian City:

Second Parent/Guardian State:

Second Parent/Guardian Zip Code:

Second Parent/Guardian Home Phone:

Landline only. Please use xxx-xxx-xxxx format.

Emergency and Medical Information

* Emergency Contact (First and Last Name):

Please list someone other than the Parents/Guardians named above.

* Relationship to Student:

* Emergency Contact Phone Number:

Please use xxx-xxx-xxxx format.

Additional Emergency Contact Phone Number:

Please use xxx-xxx-xxxx format.

* Please describe any physical or emotional conditions your child has which the Temple staff must be aware of:

* Please describe any health conditions your child has which the Temple staff should be aware of:

* List any medications your child must take during the weekend:

* List all of your child's allergies including environmental, foods, drugs and/or insect stings:

* Does your child have asthma?

YesNo

If your child has allergies or asthma, describe them and list the treatment:

PARENT:

1. My child has no physical or emotional problems which may be aggravated by events unless mentioned above.
2. The health history is correct as far as I know and the person herein described has my permission to engage in all planned activities, except as noted on this form.
3. In the event of a medical emergency, I give permission to the physician selected by the temple staff to secure proper treatment for my child as named above. We agree to pay any and all charges which may result from such treatment.

* Acknowledgement by Parent or Guardian

First and Last Name

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Thu, December 26 2024
25 Kislev 5785

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: 9:00am

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