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Parent/Guardian #1
Parent/Guardian #2
Student Information
EMERGENCY CONTACTS
Please provide us with two Emergency Contacts to be notified if both parents/guardians are unreachable.
PARENTAL AGREEMENT AND RELEASE: I approve of the above registration for my child/ren. I understand that the Director of Education or another member of the temple staff will contact me in case of emergency. If I am going to be out of town, I will provide information as to how I can be reached in case of an emergency. I hereby grant permission for my child to be treated by qualified medical authorities as necessary, and I give permission to the Director to hospitalize, secure proper treatment, order injection, anesthesia, or surgery for my child. I agree that we, our heirs, next of kin, guardians, successors and assigns or any other representative of ours will not sue, claim against, attach the property of or prosecute Congregation B’nai Israel or any of its directors, officers, agents and employees, and all affiliated entities for loss of property, injury, harm, accident, illness, loss of limb or life, or other personal injury, incapacity, medical cost, expense, damage, claim, liability, howsoever caused, and regardless of whether caused directly or indirectly, by their acts or any other acts, arising out of or in connection with the child’s participation in religious school and activities associated with CBI. The undersigned parent/guardian fully understands that s/he is responsible to pay all costs incurred as a result of the foregoing.
PHOTO/VIDEO RELEASE: I acknowledge that Congregation B’nai Israel is responsible for producing and publishing a variety of newsletters, brochures, videos, flyers and social media publicity. I hereby authorize CBI to use, reproduce or publish photographs or videos of my child/children or of me which may be taken during our participation in religious school and educational activities for any purposes without compensation to me or my child/children.
ASSUMPTION OF RISK AND WAIVER OF LIABILITY AND AGREEMENT TO ABIDE BY CONGREGATION B'NAI ISRAEL COVID-19 PROTOCOLS: The novel coronavirus (or COVID-19) has created a pandemic resulting in a State of Emergency in California. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and health officers have required or recommended social distancing and, in many instances, have prohibited or significantly limited the congregation of groups of people. Congregation B'nai Israel (CBl) is complying with guidance and taking reasonable steps to mitigate the risk of spreading COVID-19. However, this risk cannot be completely eliminated and CBI cannot guarantee that you and, your child(ren) will not become infected with COVID-19. Further, participating in Kesher programs and related events and activities could increase your and your child(ren)'s risk of contracting COVID-19. Consequently, for the safety our congregants and visitors, CBI requires all persons participating in Kesher programs during this pandemic to acknowledge an assumption of the risk, waive (i.e. release) liability and agree to abide by our COVID-19 protocols as follows: 1. Assumption of Risk. By signing this agreement, I understand and acknowledge the contagious nature COVID-19 and voluntarily assume the risk that I and, my child(ren) may be exposed to or infected by COVID-19 by participating in the Kesher Program, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 by having my child(ren) participate in Kesher programs may result from the actions, omissions or negligence of myself and others, including, but not limited to, other participants or CBI officials, employees, volunteers, and/or representatives. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any harm, loss, or injury to myself and/or, my child(ren), including, but not limited to, any injury, disability, death, illness, damage, loss, claim, causes of action, liability, cost or expense of any kind, that l, or, my child(ren), may experience or incur in connection with the CBI Kesher Program. 2. Waiver of Liability. ln consideration for CBI allowing my (child(ren) to participate in the Kesher Program, I, on behalf of my child(ren), hereby release covenant not to sue, discharge, and hold harmless the CBl, and any officials, employees, volunteers, and/or representatives thereof ("Releasee"), of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of CBI, its officials, employees, volunteers, and/or representatives, whether a COVID-19 infection occurs before, during, or after participation in the Kesher Program. 3. Agreement to Abide by COVID-19 Protocols. a. I agree that my child(ren), will not enter CBI grounds or facilities if I am, and/or they are, feeling ill, which includes, but is not limited to, the following symptoms: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, etc. b. I understand and acknowledge that I, or, my child(ren), may be denied entrance or admittance if CBI determines that I am, or they are showing any such symptoms, I warrant and represent that I am not aware of any medical condition of myself and/or my child(ren) which would render it inappropriate for me and/or them to participate in the Kesher Program. c. l agree to abide by all COVID-19 guidelines and other COVID-19-related policies and procedures, which may change overtime as circumstances change overtime. This may include hand washing requirements and temperature checks for myself and, my child(ren). I agree to practice good hygiene etiquette such as sneezing into my elbow, utilizing tissues, and avoid touching my eyes, nose, and mouth, and, if applicable to instruct my child(ren) to do the same. d. I understand and acknowledge that my failure to abide by and/or my failure to ensure that my child(ren) abides by this agreement may result in me and/or, my child(ren) being removed from the Kesher program. By entering your name below, you are agreeing to this assumption of risk and waiver of liability and agreement to abide by CBI COVID-19 protocols, fully understanding its terms
Congregation B'nai Israel Religious School and Youth Programs Policy Statement on Vaccine Status: The Talmud tells us that “all Israel are responsible for one another” (Shavuot 39a). At Congregation B’nai Israel, we believe that every member of our community has a responsibility not only for him or herself but for other members and the good of the community as a whole. This is true for many aspects of individual and community life, including our ability to keep members of the community healthy to the best of our ability. In addition, among the highest Jewish values is Pikuach Nefesh – saving a life. The Central Conference of American Rabbis has stated “Jewish tradition would define immunization as part of the mitzvah of healing and recognize it as a required measure, since we are not entitled to endanger ourselves or the children for whom we are responsible... There are no valid Jewish religious grounds tosupport the refusal to immunize as a general principle.” Each year, the American Academy of Pediatrics publishes a “Recommended Childhood and Adolescent Immunization Schedule.” Practicing pediatricians across North America consider this the standard of care and, indeed, the context in which they practice. In addition, the Centers for Disease Control (CDC) has established vaccine standards for adults. Given the overriding Jewish value that puts a premium on maintaining health, including taking preventive measures, along with the clear public health based need to protect the Congregation B’nai Israel, community as a whole, we expect that all children and staff be immunized in the manner below. The vaccination of all members is essential in order to maintain a safe environment and decrease the risk of transmission of preventable illnesses, particularly to those who are unable to vaccinate due to age or medical contraindications. For Congregation B’nai Israel, and our parent organization, the Union for Reform Judaism (URJ), this is not an issue of individual rights and choice, but an issue of public health and policy. These guidelines are consistent with our community values and those of the URJ, as we strive to provide a safe, accessible place for all members of our community to participate, learn, and grow in their Jewish life. Policy Statement: We expect that participants in any education or camp programs that require registration at Congregation B’nai Israel, (including staff) have age-appropriate vaccines recommended by the American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC). To discuss this Immunization Policy further, please make an appointment with the Director of Education. Policy Exceptions: We recognize that individuals who have had a documented allergy or severe adverse reaction to a particular vaccine will not be able to receive further doses of that individual vaccine. In addition, individuals with medical conditions such as congenital immunodeficiency or HIV, persons receiving chemotherapy, transplant patients, and persons receiving immunosuppressive drugs and chronic steroids, will not be able to receive certain vaccines. In these instances, we understand that the person may not be fully immunized. We do expect, however, that they will be up to date on all vaccinations that they are able to have and that they inform the Director of Education of their immunization status. If your child is not fully vaccinated for any reason, we reserve the right to ask you to keep your child out of Congregation B’nai Israel programs. This way we can best reduce possible exposure for your child and the community as a whole.
Optional Donation
