Teen Madrichim Retreat Registration 2024 - Form

We are excited to come together to kick off The Gan this year with a retreat with teens and faculty! We will have opportunities for engagement, community building, and fun while also preparing for another great year in The Gan with a variety of activities and an orientation!

DATES: September 20-22, 2024
LOCATION: Camp Kalsman
TRANSPORTATION: Bus will pick up and drop from Temple Beth Am
COST: This retreat is included for all enrolled Temple Beth Am Gan 9th-12th Graders

Additional logistical details will be emailed in mid September.

If you have not yet submitted your madrichim paperwork and would like to work as one of our madrichim this year, please fill out the madrichim application and email Tammie@templebetham.org to submit your hiring paperwork.

Student Details & Parent Contact Info

* Student's Preferred Name (First & Last)

Student Pronouns (she/her, he/him, they/them, she/they/he, etc.):

* Student Grade

* Parent Name (First & Last)

* Parent Email (for confirmation details)

* Parent Phone Number

Emergency Contacts
Please provide the name and phone number for two emergency contacts.

Emergency Contact 1
(Must be a Parent or Guardian)

* Contact 1 Name

Please give us the name of a parent or guardian who can be reached during this trip in case of an emergency.

* Contact 1 Phone Number

Please give us the phone number of a parent or guardian who can be reached during this trip in case of an emergency.

Emergency Contact 2

* Contact 2 Name

Please give us the name of another trusted adult who will be able to be reached during this trip in case of an emergency.

* Contact 2 Phone Number

Please give us the phone number of another trusted adult who can be reached during this trip in case of an emergency.

Student Medical Information

* Primary Care Doctor Name

* Primary Care Doctor Phone Number

* Insurance Company Name & Policy Number

Preferred Hospital (if any)

* Will your student take medication of any kind during the retreat?

Please Select OneYesNo

Medication - If your child will take medication during the retreat, please describe the type, dosage and frequency, and any additional instructions.

Note: Medication will be kept by a supervising adult and students will be given reminders.

Allergies - If your child has allergies, please list them below.

Dietary Restrictions - If your child has any dietary restrictions, please list them below.

Please describe any other health / medical information that can help us meet your student's needs (including emotional or behavioral health).

Over-the-Counter Medication

In case of a headache or pain, my student may be given TylenolIn case of a headache or pain, my student may be given IbuprofenIn case of itching, or allergies, my student may be given BenadrylIn case of an itchy skin rash, my student may be given Hydrocortisone creamIn case of a cut, my student may be given Neosporin

Permission for Emergency Medical Treatment

Reasonable effort is made to contact and inform parents or guardian in event of medical emergency and serious injury or illness. Sometimes a parent or guardian cannot be reached. Accordingly, parents or the guardian are requested to sign the following statement:

I authorize the Temple Beth Am Executive Director or his/her representative to act on my behalf in case I/my child is the victim of serious accident, injury, or illness when immediate medical or surgical care is needed, provided the director or his/her representative makes reasonable effort first to notify me of the situation and obtain my preferences. If such efforts to get in touch with me are unsuccessful, I authorize the director (or person designated to act in his/her stead) to take such action and give such consent to medical or surgical treatment on my behalf as his/her judgment dictates.

* By typing my name below, I agree to the above "Permission for Emergency Medical Treatment" statement.

* I understand that transportation to and from the Orientation Retreat will be by a school bus unless other arrangements are made. If my student is dismissed from the Retreat, it will be my responsibility to travel to Camp Kalsman in Arlington, Washington, to pick them up.

I understand that transportation to and from the Orientation Retreat will be by a school bus unless other arrangements are made. If my student is dismissed from the Retreat, it will be my responsibility to travel to Camp Kalsman in Arlington, Washington, to pick them up.

My child plans on taking the bus to and from the retreat:

* I give permission for my student to attend the Orientation Retreat from September 22-22, 2024.

I give permission for my student to attend the Orientation Retreat from September 22-22, 2024.