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Event Promotion Request Form
Current Registration Forms
Wake Up Torah Study 2025-26
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8th/9th Grade Boston Trip 2025
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Boston Trip - 8th & 9th Grade
Saturday, April 5 - Sunday, April 6, 2025
Participant Information
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Participant First Name
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Participant Last Name
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Participant Email Address
Participant Cell Phone Number
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COVID-19 Vaccination Status
My child is fully vaccinated and I have already provided proof to Community Synagogue of Rye
My child is fully vaccinated and I will email proof of vaccination to mparness@comsynrye.org
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My child is allergic to... (if nothing, enter N/A)
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Dietary Requirements (kosher, vegetarian, celiac, lactose intolerant, etc.)(if nothing, enter N/A)
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Additional Information (if nothing, enter N/A)
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My child takes the following medication(s). Please include dosage, and timing of each medication. If none, enter N/A
My child may be given the following over the counter medications (such as headache relief medication, cough drops, decongestants, etc.):
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Family Physician Name
*
Family Physician Phone Number
*
Copy of your current health insurance card (front)
You can upload a maximum of 1 files.
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Copy of your current health insurance card (back)
You can upload a maximum of 1 files.
Parent/Guardian Information
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Parent/Guardian 1 First Name
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Parent/Guardian 1 Last Name
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Parent/Guardian 1 Email Address
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Parent/ Guardian 1 Cell Phone Number
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
*
Parent/Guardian 2 Email Address
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Parent/ Guardian 2 Cell Phone Number
Emergency Contact Information
Emergency Contact MUST be separate from Parent/Guardian
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Emergency Contact First Name
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Emergency Contract Last Name
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Emergency Contact Cell Phone Number
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Relationship to Child
Permissions
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I, the undersigned parent of the child listed above, hereby give consent and permission for my child to participate in the 8th & 9th grade trip to Boston, and I empower the Trip Staff or their agents to act for me in accordance with their best judgment in case of emergency. I hereby give permission to the physician(s) selected by the staff to hospitalize, secure proper treatment, administer medication, provide anesthesia and/or perform surgery for my child as named above. I understand that all expenses for health care and medical attention will by my responsibility.
I, the undersigned parent of the child listed above, hereby give consent and permission for my child to participate in the 8th & 9th grade trip to Boston, and I empower the Trip Staff or their agents to act for me in accordance with their best judgment in case of emergency. I hereby give permission to the physician(s) selected by the staff to hospitalize, secure proper treatment, administer medication, provide anesthesia and/or perform surgery for my child as named above. I understand that all expenses for health care and medical attention will by my responsibility.
*
I understand that Community Synagogue of Rye is not defined as an entity subject to HIPAA and therefor is not covered by HIPAA regulations concerning patient medical records. I also understand and agree that situations may necessitate that my child’s medical information be shared with the event staff. I give permission to any Health Care Provider, such as a hospital or physician, to share my child’s medical information with the event staff, for treatment purposes.
I understand that Community Synagogue of Rye is not defined as an entity subject to HIPAA and therefor is not covered by HIPAA regulations concerning patient medical records. I also understand and agree that situations may necessitate that my child’s medical information be shared with the event staff. I give permission to any Health Care Provider, such as a hospital or physician, to share my child’s medical information with the event staff, for treatment purposes.
*
I, the trip participant, will abide by the event curfew announced by the leadership.
I, the trip participant, will abide by the event curfew announced by the leadership.
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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 the Community Synagogue of Rye-Code of Conduct and the Community Synagogue of Rye Trip Brit Kehilah presented at the mandatory pre-trip orientation for teens & caregivers on Wednesday March 19, 2025 at 6:15PM.
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 the Community Synagogue of Rye-Code of Conduct and the Community Synagogue of Rye Trip Brit Kehilah presented at the mandatory pre-trip orientation for teens & caregivers on Wednesday March 19, 2025 at 6:15PM.
Program Registration Fee - $400 for registered CSR Teens members, $500 for non-registered. Financial aid is available upon request - contact
mparness@comsynrye.org
.
If you have any questions, please contact Maya Parness, Director of Youth Engagement, at
mparness@comsynrye.org
.
*
Total
CSR Teen Member - $400
CSR Teen Non-Member - $500
Mon, July 7 2025
11 Tammuz 5785
Mon, July 7 2025 11 Tammuz 5785
