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A Historic Progressive Conservative Congregation in Valley Village, CA
A Dynamic Jewish Early Childhood Center Serving Children Ages 6 Weeks to Entering Pre-K
A Jewish Day School serving students in Grades TK-6
A Historic Progressive Conservative Congregation in Valley Village, CA

USY/Kadima Medical and Transportation Form 2019-2020


Consent, Authorization, and Release

Please take a few minutes to complete this Transportation consent, medical release, and medical history form. This form must be submitted to the your Youth Director every September for each USYer/Kadimanick in the chapter. 
 

Transportation Consent:
I acknowledge and accept USY's policy to use licensed drivers over the age of 18 at all times. with full understanding of the policy and the risks involved, I give permission for my USYer/kadimanick to ride in a properly insured vehicle driven by a licensed driver over the age of 18. If there is a shortage of licensed drivers over the age of 18, I give my consent for my USYer to ride with a licensed driver under the age of 18.
If there is a shortage of licensed drivers over the age of 18, I give my permission for my USYer, who does have a valid driver's license, to drive other USYers during an event. His/her vehicle is in good working order and is covered under a liability insurance policy.

Medical Release:
I certify that my USYer is physically and psychologically able to participate in all such activities.

In case of emergency, I authorize you, as my agent and at my sole cost and expense, to engage appropriate healthcare providers to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization, or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions.

Release and Indemnification:
I expressly release and indemnify you, and hold you free and harmless, from any and all liability, charges, claims, costs, and expenses of every kind and nature whatsover, including reasonable attorney fees, in connection with acceptance and participation of my USYer in your scheduled activities.

This release and indemnification is unconditional and without reservation of any kind, except only for such acts or omissions that arise out of your intentional or negligent wrongdoing, and where this is no fault by my USYer/Kadimanick. I am fully responsible if I fail to disclose any pertinent information.
Signature of Parent/Guardian:
Please provide your electronic signature by typing your full name in the space provided above.

Release of Name and/or Image:
I/we give permission for my/our son/daughter to be photographed while participating in Kadima/USY events, and for such photographs to be used in various media publications and formats, including but not limited to web pages, newspaper articles, publications, and/or newsletter.

I/we also agree to allow such photographs to be captioned from time to time with my/our son's/daughters complete name . By my/our signature here, I/we serve notice that we do give permission for my/our son's/daughters name and/or image used in any format or publication.
Signature of Parent/Guardian:
Please provide your electronic signature by typing your full name in the space provided above.

Medical History

The information on this form will be kept strictly confidential with access only to the Youth Director and certified medical personnel. Each USYer (including Kadimaniks) must file a medical history with Adat Ari El every year. 

It is the responsibility of the parent/guardian to notify both their Youth Director of any changes that may occur after the history is submitted. 
Please enter full address: street, city, state and zip
Health History:

Please select all of the below that your USYer/Kadimanik has been diagnosed with

Medical Insurance Information:

 
The information on this form is accurate, complete, and all-inclusive, to the best of my knowledge. I understand the important of keeping this information accurate and agree to contact the youth director prior to any chapter program that my child will attend if there is a change of any kind whatsover in his/her medical condition.
Please provide your electronic signature by typing your name in the space provided above.
Tue, January 28 2020 2 Shevat 5780