EMERGENCY MEDICAL FORM FOR MARLBORO JEWISH CENTER YOUTH DEPARTMENT
NAME:______________________________________________ BIRTH DATE:____________________________________
PARENT’S TELEPHONE #_____________________________ PARENT CELL#___________________ ________________
INSURANCE CO.: _____________________________________ POLICY NUMBER:__________________________________
EMERGENCY CONTACT (NOT A PARENT) & PHONE NUMBER:_______________________________________________
Please provide details for applicable items pertaining to your child.
Allergies (Food, drug, insect or substance) __________________________________________
Current Medication(s) or Medical Treatment_______________________________________
Recent illness, injury or surgery__________________________________________________
Disability, chronic illness or condition_____________________________________________
Activity restriction or modification________________________________________________
STATEMENT AND EMERGENCY AUTHORIZATION
I (the parent or legal guardian) of the applicant state that he/she is in good/normal health has no physical or mental handicaps that would interfere with full participation in the program and has my permission to engage in all available activities except as noted under Restrictions or Modifications above. I have been made aware of the fact that the events in which my child is participating may be photographed by either amateur or professional photographers that the photographs taken may be used both for purposes of reporting on the event or for such other use as the Marlboro Jewish Center Youth organization may determine. I have no objection to the pictures taken being used at any time for promotional use. It is my understanding that by signing this document I consent to the use of the pictures just referred to for any purpose whatsoever.
In case of a medical emergency, accident or health problem where immediate treatment is deemed necessary, every effort will be made to expeditiously contact the parent(s) or guardian(s) of the participant, or the emergency contact person listed above. In the event I cannot be reached, I hereby give permission to the physician selected by the Marlboro Jewish Center Youth Director, or his/her designee, to hospitalize, secure proper and ongoing treatment and to order injection, anesthesia, or surgery for my child as named above. I am aware that this form may be photocopied for use by medical caregivers.
SIGNATURE OF PARENT OR LEGAL GUARDIAN_____________________________________________
PRINT NAME:_____________________________________ DATE:___________________________________
HAGALIL USY/KADlMA – CODE OF CONDUCT FORM (MUST BE BROUGHT TO ALL REGIONAL EVENTS INCLUDING DANCES)
PLEASE READ AND SIGN THIS CODE OF CONDUCT:
In connection with any Regional program (including dances), including travel to and from such program:
These events include (but are not limited to) the International USY Convention and USY summer programs. “The Region reserves the right to impose additional sanctions in connection with this or any other improper behavior as it sees fit.
I have read these rules and understand them fully. I certify that I will adhere to this Code and will conduct myself in a manner reflecting credit upon chapter, my congregation, community and myself. Any violation of this code of conduct may result in the participant being sent home at his/her parents’ expense. The Regional Director has the sole discretion to send a participant home.
SIGNATURE OF PARENT SIGNATURE OF USYer/Kadimanik