2018 Ski Trip Medical Form
As a precautionary measure in case of emergency, we need medical insurance information for every child.
Please fill out the form below.
If you have any questions about the event, please contact our Regional Director, Rabbi Chaim Neiditch, at 404.376.8800.
Parent's email address where you would like the confirmation email from this form to be sent
Doctor's Contact Information
Medical Practice Name
Doctor's Phone Number
Medical Insurance Information
Have you looked over everything on this form and made sure all of the information is accurate?
Yes, I have looked over everything on this form and made sure all of the information is accurate.
Digital Waiver Form
To be signed by the participant's parent or legal guardian
As per the E-SIGN bill approved by congress and signed into law, your Digital Signature below is binding as your signature on a paper contract: As legal guardian, I hereby * grant permission for my child to attend the NCSY sponsored event at the place and on the date/s stipulated in the accompanying application. * My child and I are familiar with the NCSY standards of conduct (See www.NCSY.org/standards) and we understand that if my child violates the standards or does not exercise good judgment in his/her behavior at the event, * NCSY and JSU has the right to dismiss my child without refund and discuss any disciplinary problems experienced at the event with the administration of my child’s school at JSU and NCSY’s discretion. * I am aware that I will be held responsible for any damage to public or private property that JSU and NCSY states my child caused and agree to fully reimburse all parties involved. * I further acknowledge that JSU and NCSY, at its discretion, may request that my child voluntarily undertake a non-physician administered test for drugs and alcohol, and that refusal to take such a test voluntarily or a positive result obtained from such a test will also serve as grounds for immediate dismissal. * In the event of my child’s dismissal, I acknowledge that it is my responsibility to secure immediate transportation home for my child at my sole expense. In the event I am unable to secure immediate transportation, I grant permission for NCSY and JSU to arrange transportation at my sole expense. I consent to this transportation even if unchaperoned and I agree to fully reimburse JSU and NCSY for any expenses incurred within one week of the event. * Concerning my child’s medical needs, JSU and NCSY may provide over-the-counter medication (Tylenol, Advil, Kaopectate, Benadryl, etc.) as deemed necessary. - I understand that this does not require JSU and NCSY to provide medical treatment. - I have advised JSU and NCSY of any over the counter medications which may not be administered to my child. * I certify that my child is fully capable of participating in all activities associated with this event, and that my child has no unreported physical or mental disabilities or infirmities that would restrict full participation. * I understand that in case of emergency, every effort will be made to contact me or my emergency contact. If we cannot be reached, I give permission to the physician or EMT selected by JSU and NCSY to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child. - I agree to reimburse immediately and/or accept primary financial responsibility for the total cost of all medical care provided to my child. * I acknowledge and am willing to assume and accept any risks associated with my child’s participation in any aspect of this event, and I agree that the terms of this waiver will likewise bind me, my child, my heirs, legal representatives, and assignees. * I release and will defend, indemnify, and hold harmless the Orthodox Union, NCSY, JSU, its directors, owners, agents, employees, and volunteers (“releasees”) from every claim and any liability that I or my child may allege against the releasees (including reasonable legal fees and costs) as a direct or indirect result of harm to my child while s/he is in the care of JSU and NCSY. * I grant permission for JSU and NCSY to use in their promotional materials any photograph or video images of my child which may be taken at the event and * I accept that JSU and NCSY will not be responsible for any “lost and found” items that remain unclaimed after 30 days. * I accept that JSU and NCSY reserves the right to, and grant permission to JSU and NCSY, its employees, volunteers and agents to search my child's belongings and person if it is deemed neccesary.
A parent or legal or guardian must enter his/her digital signature below:
Must be at least
Do Not Fill This Out