Washington, DC Shabbaton

Registration 2017 is now open! (Please take a moment to read the trip info page , it will answer most of your questions regarding this trip.)

Full Name*

First Name Last Name

Gender*

Female Male

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number*

Area Code Phone Number

Cell Phone*

Area Code Phone Number

E-mail*

Birth Date*

Month Day Year

Parent Name*

First Name Last Name

Parent Cell Phone*

Area Code Phone Number

Parent E-mail*

Cost includes stay in a beautiful hotel, delicious meals, all activities and transportation.

The entire cost of the weekend per person is $475
Your discounted rate per person is $399
Early Bird Special! Reserve by March 10: $275

Choose your amount:*

$475 $399 $275

Help sponsor a teen

$50 $100 $199

Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

I will DO the following:

· Be WITH my group and chaperon at all times unless given explicit permission otherwise

· Stay in my HOTEL ROOM after curfew

· DRESS respectively and preserve the integrity of the Shabbaton

· Behave RESPECTFULLY toward anyone whose way of life differs from mine

· Behave as a JEW including observing KOSHER laws and keeping to CTeen’s standards

· Contact my chaperon immediately in case of EMERGENCY

I will NOT do the following:

· Carry or use any WEAPONS including, but not limited to, guns and knives

· Behave ILLEGALLY in any way

· ABUSE or BULLY anyone in any form

· Engage in any form of INTIMATE RELATIONS with anyone

· Intentionally DAMAGE or BREAK anything in my host’s home or Shabbaton venues

· Endanger the HEALTH, SAFETY, or WELFARE of my fellow Shabbaton participants

· SMOKE, buy, or possess cigarettes

· Drink, buy, or possess ALCOHOL or DRUGS

Initials of Participant*

Initials of Parent*

Date*

Month Day Year

Emergency Contact*

First Name Last Name

Emergency Contact Number*

Area Code Phone Number

Allergies*

Activity restrictions or modifications*

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 the likeness of my child is participating may be photographed by either amateur or professional photographers, and that the photographs may be used for purposes of reporting on the event, future publications or promotional material use as CTEEN may determine.

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 CTEEN Director & Chaperones, 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 fully agree to assume any financial responsibilities that may result from the aforementioned decision taken by the aforementioned individuals. I am aware that this form may be photocopied for use by medical caregivers.

Signature of Parent*

First Name Last Name

Date of Application*

Month Day Year

Washington, DC Shabbaton

Part I: Participant Info

Parent Info

Billing Info

Part II: Code of Conduct

Part III: Emergency Info