RALFTY Hanukkah Lock In 2022

ANNUAL RALFTY HANUKKAH LOCK IN @ TEMPLE BETH OR, RALEIGH NC
Friday, December 16th 2022
5315 Creedmoor Road
Raleigh, NC 27612

ARRIVAL/DROP OFF: Friday @ 5:30 PM
DEPARTURE/PICK UP: Saturday @ 9:00 AM

*NO COST*
Late arrival/early dismissal is allowed with the approval/notification of Hannah Demick, the RALFTY Advisor. Please email her if you have questions.

Open to all TBO & RALFTY teens in grades 8-12.

*Teens that drive themselves to the event can NOT leave TBO property during the event without written notice from their parents. Teens are expected to stay the entirety of the event unless they have notified Hannah otherwise.

* Email for Registration Confirmation

Additional Donation towards the event/ RALFTY Youth Group Future Events

Total amount billed

Medical Fields *FOR NON TBO RALFTY MEMBERS*

* Is the participant a member of TBO AND has their up-to-date insurance information on file?

If the participant is NOT a member of TBO, please provide their insurance information. If they are a member of TBO and their insurance information on file is up to date, you do not need to provide it on this form.

* Plan Name/Carrier

* Group Number

* Policy Number

* Carrier Address

* Claims/Phone Authorization Number

* Name of Insured

* Insured Relationship to Participant

Please provide specifics to the allergies identified above, e.g. which animals, what medicines, which foods, reactions to look for, treatment, etc.

Does the participant carry an Epi Pen?

Does the participant have any MEDICAL issues you would like us to know about?

Does the participant have any behavioral/anxiety/social issues you would like us to know about?

Does your participant carry any medications? Please list all and what they are used for. Ex. Inhaler, Anxiety medication, Allergy Medication, Diabetic Equipment, etc.

Participant Information

* Participant First Name

* Participant Last Name

* Participant's Grade

* Participant's Date of Birth

Participant's Cell Phone

Participant's Email

* Participant Street Address

* Participant City

* Participant State

* Participant ZIP Code

Participant's Gender Identity

Is there anything else we should know about the participant's gender identity so we can best support them?

Parent/Guardian Information

* Parent 1 First Name

* Parent 1 Last Name

* Parent 1 Email

* Parent 1 Cell Phone Number

Parent 2 First Name

Parent 2 Last Name

Parent 2 Email

Parent 2 Cell Phone Number

Emergency Contact Information
*We will always attempt to contact Parent 1 & 2 prior to the Emergency Contact. Please list someone other than Parent 1 or 2.

* Emergency Contact First Name

* Emergency Contact Last Name

* Emergency Contact Phone Number

* Emergency Contact Relationship to Participant

Congregation Affiliation Information

Is your family a member of Temple Beth Or? (Hosting Congregation)

Is the participant currently enrolled in TBO Religious School?

Has your teen been to a RALFTY event before?

*Electronic Signature Required

Waiver

The undersigned acknowledges that an online signature will, for all purposes, be treated as an original.

* Parent/Guardian Signature

I authorize future communications via mail, email, text and phone for the purposes of transactional communications as well as marketing communications for this and other URJ/NFTY/NFTYx programs. Please know that we do not sell or market email addresses. If you do not wish to receive further communications from the URJ and URJ affiliates you will be able to opt out at the time of receipt.

I authorize the use of Participant name, social media user information, and contact information for purposes of URJ and URJ partners/affiliates marketing now known or hereafter devised, worldwide in perpetuity until such time that I choose to unsubscribe.

I consent to the recording, use and reuse by the Union for Reform Judaism (“URJ”) and any of its respective licensees, assignees, parents, subsidiaries or affiliated entities and each of the respective employees, agents, officers and directors (collectively “Releasees”) of the Participant’s voice, actions, likeness, name, appearance and biographical material (i.e. collectively “Likeness”) in any and all media now known or hereafter devised, worldwide in perpetuity. I agrees that Releasees may use all or any part of their Likeness, and may alter or modify it regardless of whether or not the attendee is recognizable. I further agree that Releasees may use the Participants Likeness and the Materials in connection with any promotion, publicity, marketing or advertisement for the Releasees. I releases Releasees from any and all liability arising out of their use of the Participant’s Likeness and/or the Materials. I agrees not to make any claim against Releasees as a result of the recording or use of the Partcipant’s Likeness and/or the Materials (including, without limitation, any claim that such use invades any right of privacy and/or publicity).

By signing below, parent or guardian on behalf of each Participant and all parties responsible for Participant, confirms that they have read and understood the NFTY B’rit Kehillah, and the rules including those on disciplinary action and indemnification expressly provided immediately above, and agree with all provisions contained herein.

* Parent/Guardian Signature

Terms and Conditions Agreement:
The below Terms and Conditions between Temple Beth Or and my child (hereafter “Participant”) represent the expectations and agreements in order to participate in a Temple Beth Or-sponsored activity:

In the mutual interests of Temple Beth Or, the Participant, and for the well-being of all participants at Temple Beth Or, I understand, respect and will observe the rules, regulations and policies of Temple Beth Or, which have been developed for the benefit of all participants including Participant to strengthen the Temple Beth Or program and enhance the experience for all participants. As parent/guardian of Participant, I agree to the implementation and enforcement of the following rules, regulations and policies for Temple Beth Or program

Requirements for Acceptance to Session at Temple Beth Or:

I agree that the Participant's participation in Temple Beth Or activities is not confirmed until explicit written verification is received from Temple Beth Or, which notice will usually come to Participant and his/her family, including me, via email.

Waiver

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