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Date of Birth: ____________________________
THIS CONSENT, AUTHORIZATION, AND RELEASE (“Consent”) is provided to UNITED SYNAGOGUE YOUTH, SE REGION, a department of the United Synagogue of Conservative Judaism, with regional headquarters in Boca Raton FL (“USY”) in connection with Mercaz Chapter President’s Weekend, to be held at Beth El Birmingham, AL, ,Sept. 5-7, 2008. (“Scheduled Activity”).
1. The minor has my consent to attend and to participate in the Scheduled Activity. There are no limitations or restriction of any kind whatsoever on such participation unless this box, _____ is checked with explanation attached to this form.
2. The Minor has been instructed by me, and understands and agrees, to comply with all rules, regulation, and Codes of Conduct established by USY and the official instructions and directives of all authorized staff members, volunteers, agents, and employees (“Personnel”) of USY.
3. You are expressly authorized to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions, acting as my authorized agent and at my sole cost and expense. There are no exceptions or limitations, or other special instructions, in connection with the foregoing, unless this box _____ is checked, with explanation attached to this form.
4. Unless this box _____ is checked and I have provided you with specific instructions, directions or other specific data to the contrary, on an attached page, you assume that the Minor has no medial disabilities, allergies or other limitations or any kind whatsoever that might in any way limit participation in the Scheduled Activity.
5. I expressly release and agree to indemnify and hold USY (and its Personnel) free and harmless from any and all liability, charges, claims, costs, and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with the acceptance and participation of the Minor in the Scheduled Activity. The foregoing Release is without reservation of any kind except only for such acts or omissions on your part that arise out of your intentional or negligent wrongdoing and without fault of any kind on the part of the Minor or on my part in failing to disclose pertinent information to you.
6. I represent to you that I have the sole, full and legal power and right to execute this Consent, and that you will rely on my representations.
7. If this consent is signed by more than one person, all references to the singular shall include the plural, jointly and severally.
I DECLARE UNDER THE PENALTY OF PERJURY THAT I HAVE READ AND FULLY UNDERSTAND THE IMPORTANCE AND THE EFFECT OF THE FOREGOING CONSENT, AUTHORIZATION, AND RELEASE: THAT I HAVE OBTAINED SUCH ADVICE OF AN ATTORNEY AND OF A LICENSED PHYSICIAN AS I DEEMED NECESSARY, TO MY COMPLETE SATISFACTION; AND THAT I SIGNED THIS CONSENT ON ___________________, 20___.
Signed __________________________________________________*_____________________________
Signed __________________________________________________*___________________________
Relationship to Minor__________________________________
Insurance Company Name _______________________________Policy Number __________________
Address _______________________________________________ Phone _________________________