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Kol Ami Youth (Retreat Weekend) May 24-26
Parent Permission/Medical Release Form
Code of Conduct
Permission & Medical Release
My son/daughter has permission to attend the RAC event in Washington DC, March 1-4
I/we understand and accept that Kol Ami cannot guarantee personal safety or the safety of property while participating in this trip and activities.
I hereby release Kol Ami, its officers, directors, and employees, from any and all claims that I may have relating to injury or damage suffered or incurred by me or my child in connection with the above described inherent risks. I hereby give permission to the physician selected by the advisor to hospitalize, give necessary treatment, or give anesthesia to my child, as named above, in the event that I cannot be reached by phone in an emergency. I understand that the advisor of the trip will try to reach me at any time of emergency and that a treatment plan will be acted upon without my notification only if I am unreachable.
Medical Insurance Company Name
Medical Insurance Policy Number
Other Vital Information For the Care of Your Child
By checking this box, I authorize the trip advisor to administer the following over the counter medications to my child, should he/she need them for headache, stomach ache, etc. (Tylenol, tums, Pepto Bismol, Benadryl, Motrin)
Please notify me before administering ANY over the counter medication to my child.
Please list any allergies (food, drugs, etc.,)
Does your child take regular medication?
If your child is taking medication you must complete a medication form that can be found at www.NYKolAmi.org/medication.
Check this box if you don't want your child photographed.
By not checking no, you are agreeing that your child’s likeness may be photographed, recorded, reproduced, and used for school-wide publications, professional communications, and marketing efforts of Congregation Kol Ami including but not limited to the yearbook, photo galleries, classroom pages, news stories, emails to parents and other family members, Facebook, Instagram, Twitter, CRS website, internet, achievement announcements, and printed internal publications. No student will be identified by name in any photo or video posted online
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Parent Contact Information
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Other Family or Friend to Contact in Case of Emergency
Other Contact Name
Other Cell Phone
Relationship To Family
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Code Of Conduct
I will promote the creation of a religious youth community based on the mutual respect and a sense of personal well-being. I will treat others with
(honor and respect) because we are created
(in the image of God). I have read the following rules, designed to promote both health and safety of all event participants, and have indicated my complete acceptance by my signature and that of my parent/guardian.
I will not possess, consume, or distribute alcoholic beverages, other than that served by adult leadership for Jewish sacramental purposes, even if I am of legal drinking age.
I will not possess, use, or distribute any illegal drug or drug paraphernalia.
I will not smoke or consume or distribute tobacco products at any time during the event.
I will attend and participate fully in the entire event, unless otherwise agreed upon with the Director of Youth Engagement. I will arrive on time, stay until the end, and remain on the event premises at all times.
I will not bring or use any weapons, firearms, or anything that may be construed as a weapon.
I will not commit any illegal act. I understand that vandalism, disturbing the peace, or other inappropriate behavior as determined by the adult leadership in accordance with the youth leadership will not be tolerated. I understand that I will have to pay for any damage that I cause. I understand that no gambling is allowed, except for fundraisers approved by the adult leadership.
I will abide by the event curfew announced by the leadership.
I understand that no guests are allowed at any event, unless the adult leadership grants permission in advance, and that any unauthorized guests will be asked to leave immediately.
I will not participate in any activities that could be deemed as hazing, sexually harassing, demeaning, or hurtful.
I agree to refrain from sexual behavior.
I agree to abide by any additional rules, pertinent to a specific event, which may be announced, and to accept the consequences of their violation.
By checking this button I indicate that I understand that these rules of behavior apply from the time I leave home for the event, during the event itself, and until I return home after the event.
We understand that part of the Kol Ami experience involves activities, group living arrangements and interactions that may be new to my child. These things come with certain risks and uncertainties beyond what my child may be used to dealing with at home. I am aware of these risks, and I am assuming them on behalf of my child. I realize that no environment is risk free and so I have instructed my child on the importance of abiding by Kol Ami’s Brit Kehilah (Code of Conduct). My child and I both agree that he or she is familiar with these rules and will obey them. We further understand that sanctions imposed by the Director of Youth Engagement for violation could include immediate expulsion from the event, at the expense of the parent or guardian.
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