Youth Group Membership Form 2023-2024

Temple Dor Dorim
Youth Programs
2023-2024 School Year

Jamie Mafdali, RJE
Director of Youth Engagement & Communications and Program Facilitator
jmafdali@templedordorim.org

2360 Glades Circle · Weston, FL 33327 · Phone: 954-389-1232 · Fax: 954-389-4670 · dordorim.org

Temple Dor Dorim Youth Programs

INFORMAL EDUCATION AND YOUTH PROGRAMS

Our programs blend social activities with Jewish values and spirituality, while developing leadership skills. All Religious School students are automatically enrolled in our Temple youth programs and we encourage active participation.
Connecting our youth to synagogue life is a vital part of enriching our children’s growth, focusing on building lifelong Jewish identities and friendships.
- Gesher (K-Grade 2)
- Giborim (Grades 3-5)
- ATID (Grades 6-8)
- TOUCHY (Grades 9-12)

PARTICIPANT INFORMATION

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

* Date of Birth

* Hebrew Name

* Grade Level as of 9/2023

Participant’s Email Address

(6th grade and up)

Participant’s Cell Phone

(6th grade and up)

* Student T-Shirt Size:

* Does your child have an IEP/504?

(if yes, please attach a copy below)

Name of Secular School

PARTICIPANT MEDICAL INFORMATION
All information is strictly confidential except where needed (on file in the office and with the teacher).

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

* Does your child take Medication regularly?

Please list Allergies and/or Medical Conditions here

Please list Medications here

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

Please explain anything additional here

* YOUTH PROGRAM REGISTRATION

Click the "" to start adding additional 2023-2024 Youth Program Participants.

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

* Date of Birth

* Hebrew Name

* Grade Level as of 9/2023

Student’s Email Address

(6th grade and up)

Student’s Cell Phone

(6th grade and up)

* Student T-Shirt Size:

* Does your child have an IEP/504?

(if yes, please attach a copy below)

Name of Secular School

STUDENT MEDICAL INFORMATION
All information is strictly confidential except where needed (on file in the office and with the teacher).

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

* Does your child take Medication regularly?

* Please list Allergies and/or Medical Conditions here

* Please list Medications here

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

* Please explain anything additional here

* RELIGIOUS SCHOOL & YOUTH PROGRAM REGISTRATION

SECURITY FEE
A security fee of $136 is assessed at the time of registration to cover the cost of a security detail being on the premises during school hours.

$136/per student

Click the "" to add another 2023-2024 Religious School & Youth Program Student.

IEP/504 FILE UPLOADS

PARENT/GUARDIAN INFORMATION

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

Please Select OneYesNo

PRIMARY PARENT/GUARDIAN

SECONDARY PARENT/GUARDIAN

* First Name

* Last Name

Mobile

Work Phone

* Email

HOME ADDRESS

* Address

* City

* State

* Zip Code

Home Phone (if applicable)

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

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

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 Temple Dor Dorim to use my child’s likeness, photograph, or video in any publication, advertisement, display or other medium in connection with the programs, activities, and events of Temple Dor Dorim.

ONLINE PROGRAMMING (IF NEEDED)
I agree that my child/children may be in a one-on-one setting, online, with an adult or teen.

I agree that my child/children will be participating with someone at home who is responsible for the physical well-being of my child.

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
As parent/guardian of my child/children, in the event that I cannot be reached in an emergency, I give express permission for Temple Dor Dorim to secure proper medical treatment for my child at a hospital or with a physician selected by Temple Dor Dorim. I hereby grant express permission to the physician or hospital selected by the Temple to hospitalize, treat, order injection or anesthesia, or perform surgery for my child. Furthermore, I accept full responsibility for any such services rendered.

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

ENROLLMENT AGREEMENT
I hereby enroll my child in TDD Youth Programs and grant permission for my child/children to participate in all aspects of the TDD program for the 2023-2024 school year.

* Parent/Guardian Signature

* Date

FINANCIAL RESPONSIBILITY

* I understand that enrollment in TDD Youth Programs for Kindergarten through 5th Grade also requires current requirements of Temple membership. All Temple membership accounts must be in good standing to complete registration.

I understand that enrollment in TDD Youth Programs for Kindergarten through 5th Grade also requires current requirements of Temple membership. All Temple membership accounts must be in good standing to complete registration.

* I understand that I must notify Temple Dor Dorim when my credit card expires or is canceled and supply them with my updated card number. If credit card is declined, a replacement must be given within 10 days. TDD reserves the right to terminate participation due to failure to meet financial obligation.

I understand that I must notify Temple Dor Dorim when my credit card expires or is canceled and supply them with my updated card number. If credit card is declined, a replacement must be given within 10 days. TDD reserves the right to terminate participation due to failure to meet financial obligation.

* I understand that upon RSVP my credit card on file will be charged for any Youth Group event for which there is a charge.

I understand that upon RSVP my credit card on file will be charged for any Youth Group event for which there is a charge.

* I understand that Youth Group Membership Dues cannot be refunded after September 1, 2023.

I understand that Youth Group Membership Dues cannot be refunded after September 1, 2023.

YOUTH SCHOLARSHIP FUND
The Youth Scholarship Fund allows the youth of Temple Dor Dorim to be even more deeply involved in programs locally, throughout the country, and in Israel. We would like to make a donation to the Rabbi Norman & Shoshi Lipson Youth Scholarship Fund.

Other Amount

2023-2024 YOUTH PROGRAMS - TOTAL

Sat, April 27 2024 19 Nisan 5784