College Caravan 2023

College Caravan

9th - 12th Grades

On the College Caravan, we’ll tour Florida campuses, meet with admissions counselors, visit Hillel, and meet with current students from our congregations.

$125 Per Broward Teen
$425 Per Non-Broward Teen
Includes charter bus, hotel, all meals, and Shabbat dinner at University of Florida Hillel.

Limited Spaces Available.

Contact Jamie Mafdali or your Youth Professional.
JMafdali@templedordorim.org | 954-389-1232

PARTICIPANT INFORMATION

* Participant's Name (First, Middle, and Last)

* Date of Birth

* Grade Level as of 9/2023

* Participant’s Email Address

* Participant’s Cell Phone

* Student T-Shirt Size:

Name of Secular School

* How did you hear about the College Caravan? Are you affiliated with a congregation?

PARTICIPANT MEDICAL INFORMATION
All information is strictly confidential among trip staff and/or volunteers.

* Does your child have Allergies and/or a Medical Condition?

* Does your child take Medication regularly?

Please list Allergies and/or Medical Conditions (physical or mental) here. If none, please type N/A.

Please list Medications here. Include dosage and times taken.

Please note that all participants will be responsible for taking their medication on their own.

* Insurance Information - Please list the following:
Carrier/Plan Name
Group #
Policy #
Carrier Address
Claims/Phone
Authorization #
Co-Pay Amount
Name of Insured
Relationship to Participant

* Prescription Plan Information - Please list the following:
Carrier/Plan Name
Group #
Policy #
Prescription Information #
Claims/Phone
Authorization #
Co-Pay Amount (Generic & Brand)
Name of Insured
Relationship to Participant

* Is there anything else we should know about your child?

Please explain anything additional here

* REGISTRATION

Please select an option below based on where you live.Broward County Resident | $125
Thanks to the generosity of Jewish Federation of Broward CountyNon-Broward Resident | $425

PARENT/GUARDIAN INFORMATION

* Is there more than one parent/guardian to add to this application?

Please Select OneYesNo

PRIMARY PARENT/GUARDIAN

SECONDARY PARENT/GUARDIAN

* First Name

* Last Name

* Mobile

Mobile

Work Phone

* Email

HOME ADDRESS

* Address

* City

* State

* Zip Code

Home Phone (if applicable)

* I've checked all the prepopulated information above for accuracy and made changes if necessary.

All of the information was correct. I made no changes.I made changes and the information is now correct.

EMERGENCY CONTACTS
(other than Parent/Guardian)

* Emergency Contact - Name & Relationship

* Emergency Contact - Cell or Home Phone

Emergency Contact - Name & Relationship

Emergency Contact - Cell or Home Phone

PUBLICITY RELEASE
As parent/guardian of my child, I grant permission for my child’s likeness, photograph, or video to be used in any publication, advertisement, display or other medium in connection with the programs, activities, and events of Temple Dor Dorim, other participating congregations, and Jewish Federation of Broward County.

IMMUNIZATION CERTIFICATION
As parent/guardian of my child/children, I confirm that my child/children have completed the age-appropriate vaccine schedule recommended by the Centers for Disease Control and Prevention (CDC).

AUTHORIZATION FOR EMERGENCY MEDICAL/SURGICAL TREATMENT
I hereby give permission to the College Caravan staff/Volunteers to act for me in accordance with their best judgment in case of an emergency.
I, as parent/guardian, hereby authorize the College Caravan staff/volunteers to make any and all medical decisions while my child is in their care and custody from November 9 - November 11, 2023. I also hereby grant the College Caravan staff/volunteers a limited HipaA authority to receive any and all medical information including but not limited to diagnosis and treatment during the time of November 9 - November 11, 2023 while my child is in their care and custody. I hereby grant express permission to the physician or hospital selected by the College Caravan staff/volunteers to hospitalize, treat, order injection or anesthesia, or perform surgery for my child. Furthermore, I accept full responsibility for any such services rendered. The College Caravan staff/volunteers have been given authority to travel and transport my child throughout Florida during the dates of November 9 - November 11, 2023.

CODE OF CONDUCT
I will promote the creation of a unified and meaningful community based on mutual respect and a sense of personal well-being.

I have read the following rules, designed to promote the health and safety of all event participants, and have indicated my unqualified acceptance by my selection below and that of my parent/guardian.

1. I will not possess, consume, or distribute alcoholic beverages.
2. I will not possess, use, or distribute any illegal drug or drug paraphernalia.
3. I will not smoke or consume tobacco products including vaping.
4. I will participate fully in the entire program. I will arrive on time, pay careful attention to the program, and remain with the group in designated areas at all times.
5. I will not commit any illegal act. I understand that vandalism, disturbing the peace, or other inappropriate behavior as determined by the adult leadership will not be tolerated. I understand that I will have to pay for any damage that I cause.
6. I will abide by the curfew announced by the adult leadership.
7. I understand that no guests are allowed at any venue, unless the chaperons grant permission in advance, and that unauthorized guests will be asked to leave immediately.
8. I agree to refrain from inappropriate sexual behavior both physical and verbal.
9. I agree to abide by any additional rules pertinent to the event, which may be announced, and to accept the consequences of their violation.
10. I agree to respect the adult leadership, my fellow participants, and myself while adhering to the rules above stated above.

We have read the preceding rules, and fully understand them. We understand that sanctions imposed by the adult leadership for violation could include immediate exclusion from the remainder of the event, and that I may have to pick my child up at my own expense. If my child is a participant who is under the guise of the grant, if they are asked to go home, we will need to pay the full balance of the trip ($425).

WELLNESS PROTOCOLS
Individuals who are sick will not be allowed to participate in the College Caravan if they have any of the following symptoms: fever, coughing, sneezing, shortness of breath, difficulty breathing, sore throat, loss of smell or taste, chills, muscle pain, headache, runny nose, rash, abdominal pain, diarrhea, vomiting, or lethargy.

WAIVER OF LIABILITY AND INDEMNITY, ASSUMPTION OF RISK AND RELEASE

Click the "" to READ & SIGN our Waiver of Liability and Indemnity, Assumption of Risk and Release

* Parent/Guardian Name

* Child/Children Name(s)

IN CONSIDERATION for being permitted to utilize the services, and programs of the Temple Dor Dorim and ECC (the “TDD AND TDD ECC”) and/or for my child(ren) listed above to participate for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any off-site program affiliated with the TDD AND TDD ECC, the undersigned, on behalf of himself or herself and such participating child(ren) and any personal representatives, heirs, and next of kin (hereinafter referred to as the “undersigned”) hereby acknowledged, and agrees and represents that he or she has inspected and carefully considered such premises, equipment and facilities and/or the affiliated program and that the undersigned acknowledges and accepts same as being safe and reasonably suited for the use or participation by the undersigned and such participating child(ren).

The undersigned further hereby agrees, represents, and warrants that neither the undersigned nor any persons under the undersigned’s control shall visit or utilize the facilities, services, and programs of TDD AND TDD ECC if he or she (i) experiences symptoms of COVID-19, including, without limitation, fever, cough or shortness of breath, or (ii) has a suspected or diagnosed/confirmed case of COVID-19. The undersigned agrees to notify TDD AND TDD ECC immediately if he or she believes that any of the foregoing symptoms or access/use restrictions may apply.

TDD and TDD ECC has taken and may take certain steps to implement recommended guidance and protocols issued by the Public Health Agencies for slowing the transmission of COVID-19, including, without limitation, the access/use restrictions set forth above. The undersigned acknowledges and agrees that the TDD AND TDD ECC may revise its procedures at any time based on updated recommended guidance and protocols issued by the Public Health Agencies and further agrees to comply with the TDD AND TDD ECC’s revised procedures prior to utilizing the facilities, services, and programs of the TDD AND TDD ECC.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE TDD AND TDD ECC FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH THE TDD AND TDD ECC, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

THE UNDERSIGNED, ON HIS OR HER BEHALF AND ON BEHALF OF SUCH PARTICIPATING CHILD(REN), HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE THE TDD AND TDD ECC, THE REFORM CONGREGATION OF WESTON, INC. (d/b/a Temple Dor Dorim), its/their directors, officers, employees, volunteers and agents from any and all liability to the undersigned or such participating child(ren) and all personal representatives, assigns, heirs, and next of kin of the undersigned or such participating child(ren) for any loss or damage, and any claim or demands on account of any property damage or any injury to, or an illness or the death of, the undersigned or such participating child(ren) (or any person who may contract COVID-19, directly or indirectly, from the undersigned or such participating child(ren)) whether caused by any action or the negligence, active or passive, of the TDD AND TDD ECC or otherwise while the undersigned of such participating child(ren) are in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the TDD AND TDD ECC.

THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS THE TDD AND TDD ECC, THE REFORM CONGREGATION OF WESTON, INC. (d/b/a Temple Dor Dorim), it’s/their directors, officers, employees, volunteers and agent, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, or otherwise while the undersigned or any participating child is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the TDD AND TDD ECC. The undersigned understands and agrees that the TDD AND TDD ECC is not required to provide insurance to cover the undersigned or such participating children in the event they suffer illness, injury, death, property loss, theft or damage of any sort upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the TDD AND TDD ECC.

The undersigned agrees and acknowledges that use of the TDD AND TDD ECC facilities and services, and participation in the TDD AND TDD ECC programs, may involve inherent danger and risk, including, without limitation, the risk of physical illness or injury, death or property damage. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF ILLNESS, BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such participating children due to negligence, active or passive, or otherwise while in, about or upon the premises of the TDD AND TDD ECC and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the TDD AND TDD ECC. The undersigned acknowledges that any illness or injuries that the undersigned or such participating child(ren) contract or sustain may be compounded by negligent first aid or emergency response of the TDD AND TDD ECC and waive any claim in respect thereof.

The undersigned agrees to fully indemnify and hold TDD AND TDD ECC harmless for any and all losses, including but not limited to damages and attorney’s fees and costs, whether incurred or imposed upon TDD AND TDD ECC as a result of any activity, loss, injury or condition covered by this Agreement.

THE UNDERSIGNED further expressly agrees that the foregoing WAIVER OF LIABILITY AND INDEMNITY, ASSUMPTION OF RISK AND RELEASE AGREEMENT is intended to be as broad and inclusive as is permitted by the laws of the State of Florida and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

* I HAVE CAREFULLY READ AND VOLUNTARILY SIGN THIS WAIVER OF LIABILITY AND INDEMNITY, ASSUMPTION OF RISK AND RELEASE AGREEMENT AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS OF INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE. I AM AWARE THAT BY AGREEING TO THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES FROM THE TDD AND TDD ECC IN CASE OF ILLNESS, INJURY, DEATH OR PROPERTY LOSS OR DAMAGE, INCLUDING, FOR THE AVOIDANCE OF DOUBT AND WITHOUT LIMITATION, EXPOSURE TO COVID-19 AT ANY TDD AND TDD ECC FACILITY OR PROGRAM AND ANY ILLNESS, INJURY OR DEATH RESULTING THEREFROM. I UNDERSTAND THAT THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF AND INDEMNIFICATION FOR ALL CLAIMS. IF SIGNING ON BEHALF OF MINOR: I ALSO UNDERSTAND THAT THIS AGREEMENT IS MADE ON BEHALF OF MY MINOR CHILD(REN) AND/OR LEGAL WARDS AND I REPRESENT AND WARRANT TO THE TDD AND TDD ECC THAT I HAVE FULL AUTHORITY TO SIGN THIS AGREEMENT ON BEHALF OF SUCH MINOR(S).

I HAVE CAREFULLY READ AND VOLUNTARILY SIGN THIS WAIVER OF LIABILITY AND INDEMNITY, ASSUMPTION OF RISK AND RELEASE AGREEMENT AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS OF INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE. I AM AWARE THAT BY AGREEING TO THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES FROM THE TDD AND TDD ECC IN CASE OF ILLNESS, INJURY, DEATH OR PROPERTY LOSS OR DAMAGE, INCLUDING, FOR THE AVOIDANCE OF DOUBT AND WITHOUT LIMITATION, EXPOSURE TO COVID-19 AT ANY TDD AND TDD ECC FACILITY OR PROGRAM AND ANY ILLNESS, INJURY OR DEATH RESULTING THEREFROM. I UNDERSTAND THAT THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF AND INDEMNIFICATION FOR ALL CLAIMS. IF SIGNING ON BEHALF OF MINOR: I ALSO UNDERSTAND THAT THIS AGREEMENT IS MADE ON BEHALF OF MY MINOR CHILD(REN) AND/OR LEGAL WARDS AND I REPRESENT AND WARRANT TO THE TDD AND TDD ECC THAT I HAVE FULL AUTHORITY TO SIGN THIS AGREEMENT ON BEHALF OF SUCH MINOR(S).

* I have read and understand the terms of this Assumption of Risk, Release and Waiver of Liability, and Indemnity Agreement and agree to its terms.

I have read and understand the terms of this Assumption of Risk, Release and Waiver of Liability, and Indemnity Agreement and agree to its terms.

* Parent/Guardian Signature

* Date

* Emergency Contact Name

* Emergency Contact Number

* Parent/Guardian Signature

* Date

TOTAL

Sat, April 27 2024 19 Nisan 5784