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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
 
(6th grade and up)
(6th grade and up)

 
(if yes, please attach a copy below)

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

 
Click the "" to start adding additional 2023-2024 Youth Program Participants.
(6th grade and up)
(6th grade and up)

 
(if yes, please attach a copy below)

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

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

 

 
 


 
PARENT/GUARDIAN INFORMATION
 
PRIMARY PARENT/GUARDIAN
 
    SECONDARY PARENT/GUARDIAN
 

 
HOME ADDRESS
 

 
 


 
EMERGENCY CONTACTS
(other than Parent/Guardian)
 


 
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
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.

 

 

 
 
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.
 


 
FINANCIAL RESPONSIBILITY
Sat, October 5 2024 3 Tishrei 5785