TZAFON FALL KALLAH ‘13 Registration Form
Please return this ENCAMPMENT ’12 packet, all listed paperwork, and full payment to the address listed below. Consult the
checklist at the bottom of this form to ensure that you turn in a complete application packet. Registration cannot be
guaranteed without it.
BASIC INFORMATION:
Name: ______________________________________________
Address: ______________________________________________________________________________
Home Phone: ______________ USYer Cell Phone: _______________ Parent Cell Phone:_____________
Email Address: ________________________ Parent Email Address: ______________________________
Chapter: _____________________________
Please use this checklist to help ensure that you submit a complete application
packet to the address listed below by NOVEMBER 5, 2013:
____ TZAFON REGION –APPLICATION form (Only if NOT completed ONLINE)
NOTE: Completed application and payment must be received by NOVEMBER 1st.
Applications received after NOVEMBER 1st, will be accepted on a housing space available basis only, and with a
$20 late fee. Applications received after NOVEMBER 1st might not be able to be accommodated. See
cancellation policy below.
____ PAYMENT (Please see FEE PAGE)
___
CODE of CONDUCT form (Not necessary if attended ENCAMPMENT 2013)
____ Health History and Parent Questionnaire (Required for every convention)
____ Copies of present Medical Insurance Card (Front and Back)
(Not necessary if attended ENCAMPMENT 2013)
____ CONSENT, AUTHORIZATION and RELEASE form for 2013 -2014
(Not necessary if attended ENCAMPMENT 2013)
____ Medication form (Required for every convention)
NOTE: CANCELLATION POLICY:
There will be a $50 cancellation fee charged between OCTOBER 25th and
NOVEMBER 8th . All cancellations must be received BEFORE NOVEMBER 8th .
NOTE: There will be no refunds after this date – for ANY REASON.
Please make checks payable to USCJ/Tzafon USY and send them to:
TZAFON USY Encampment/Kamp Kadima,30 farmingdale Road, LATHAM, NY 12110
For more information, please call the Sandra Goldmeer, Regional Youth Director,
at 518-859-1241, or email: regionaldirector@tzafon.org
FALL KALLAH FEE PAGE
Please include this page when you return your application
COST (PLEASE CHECK ONE)
_____
GENERAL FEE $170.00.
This is our general fee for USYers.
______HOST CITY (Entire Capital District) /R.E.B./Sibling not from Capital District $155.00
This is for all participants from Capital District and any members of our Regional Executive Board ONLY.
Also any siblings who are from OUTSIDE the Capital district
______FIRST
TIMER DISCOUNT PRICE/Capital district Sibling -- $145.00
If your child has NEVER attended a Regional USY event, or they are a Sibling from the Capital District, they
qualify for this price.
______FIRST
TIMER SIBLING PRICE -- $135.00
If your child has NEVER attended a Regional USY event, and is a sibling, they qualify for this price.
** Sibling Discount Price – Sibling discounts are notated above! Note the sibling discount is
available for the Second (and subsequent) children after the first child pays the full rate.
Total Amount Enclosed $________________ (including Registration Fee and any discounts which may apply)
Please make checks payable to USCJ/Tzafon USY and send them to:
TZAFON USY, 30 farmingdale Road, LATHAM, NY 12110
For more information, please call the Sandra Goldmeer, Regional Youth Director,
at 518-859-1241, or email: goldmeer@uscj.org
PLEASE NOTE: All Participants are expected to be at the program for the entirety of the
weekend. The convention begins at 2:00 PM in Albany. This allows us to do some
initial programming before Shabbat Begins. Due to Shabbat starting so early, this will require
the USYers to miss some/all of school on Friday. If you need a letter to help your child be excused,
please let me know.
TRANSPORTATION: A bus has been chartered for pickup from centralized points in the
region for most participants outside of Albany. Note: Poughkeepsie Participants will be either
carpooling or taking the train.
A PRELIMINARY BUS SCHEDULE will be emailed upon receipt of application. However here is listed
the estimated DEPARTURE times for each city on 11/22: Buffalo: 8:45AM, Rochester: 10:00 AM,
Syracuse (& Ithaca): 11:30 AM.
NOTE: THIS FORM IS KEPT ON FILE FOR ALL REGIONAL PROGRAMS OF THIS PROGRAM YEAR
UNITED SYNAGOGUE OF CONSERVATIVE JUDAISM
DEPARTMENT OF YOUTH ACTIVITIES --TZAFON REGION
30 FARMINGDALE ROAD LATHAM, NY 12110 518.859.1241
Goldmeeruscj@gmail.com
CONSENT, AUTHORIZATION and RELEASE 2013-2014
NAME: ________________________________________, (“MINOR”)
DATE OF BIRTH: ________________
THIS CONSENT, AUTHORIZATION AND RELEASE (“Consent”) is given to The United Synagogue of Conservative Judaism, its
Northeast District, and Department of Youth Activities (collectively “USCJ/USY”) headquartered in Albany, NY, in connection with
my child’s participation in any Regional USY/Kadima Activity (“Scheduled Activity”) for the 2012-2013 Program year.
PLEASE READ AND INITIAL EACH PARAGRAPH AFTER THE PARAGRAPH NUMBER TO SHOW YOUR CONSENT AND
THEN SIGN AND DATE THE BOTTOM OF THIS PAGE.
INITIAL
1. ___ The Minor has my consent to attend and to participate in a Tzafon Regional Activity. There are no limitations or
restrictions of any kind whatsoever on such participation unless checked here ___ and an explanation is attached.
2. ___ The Minor has been instructed by me, and understands and agrees, to comply with all rules, regulations and Code of
Conduct established by USY/KADIMA and the official instructions and directives of all authorized staff members,
volunteers, agents and employees of USY/KADIMA (“Personnel”). All references to “you” or “your” mean USY/KADIMA and
its Personnel.
3. ___ You, acting as my authorized agent and at my sole cost and expense, are expressly authorized to engage appropriate
health care providers 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. There are no exceptions or limitations to the foregoing, unless checked
here____ and specific written instructions are attached.
4. ___ Unless checked here ____ and I have attached specific written instructions, directions or other specific data to the
contrary, you may assume that the Minor has no medical disabilities, allergies or other limitations of any kind whatsoever
that may limit participation in the Scheduled Activity.
5. ___ I expressly release and agree to indemnify and hold USCJ/USY, its agents, Board of Directors, employees, representatives,
and legal counsel, 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 unconditional and without reservation of any kind, except only for such
acts or omissions that arise out of your intentional or negligent wrongdoing where there is no fault by the Minor or by my
failing to disclose pertinent information to you.
6. ___ I represent to you that I have sole, full and legal power and right to execute this Consent, and acknowledge that you will
be relying on my representations and statements, and on the information supplied to me.
7. ___ If this Consent is signed by more than one person, all references to the singular shall include the plural, jointly and
severally.
8. ___ I give USCJ/USY permission to use any photographic, video or audio representations of my minor that may be taken during
the Scheduled Activity, be it in print, in Internet materials, or in other media produced by USCJ/USY for publicity,
promotional, or any other purposes without further permission.
I HAVE READ AND FULLY UNDERSTAND THE IMPORTANCE AND EFFECT OF THE FOREGOING CONSENT,
AUTHORIZATION AND RELEASE; I HAVE OBTAINED SUCH ADVICE OF AN ATTORNEY AND A LICENSED PHYSICIAN
AS I DEEMED NECESSARY BEFORE SIGNING THIS DOCUMENT; I HAVE RETAINED A COPY OF THIS DOCUMENT FOR
MY RECORDS; AND I HAVE VOLUNTARILY SIGNED THIS CONSENT ON ___________________, 20______.
Signature _______________________________Relationship to Minor
___________________
NOTE: ALL USYER’S/KADIMANIKS MUST HAVE MEDICAL INSURANCE IN ORDER TO PARTICIPATE IN REGIONAL PROGRAMS.
We provide secondary insurance for accidents and illnesses that occur during the Encampment. This means, our insurance carrier
will directly settle all charges with your health providers after your primary insurance maximum allowance has been reached in
accordance with the schedule in your policy and subject to certain provisions, limitations and exclusions in our policy.
TZAFON USY REGIONAL ACTIVITIES CODE
As a USYer, I promise that I will uphold the standards of USY. I will respect others and myself. I understand that if I fail to abide by
the standards set forth here disciplinary action may be instituted. Accordingly, I acknowledge that I have reviewed and that I
agree to the following rules of conduct. Please review and check each statement, and then sign the bottom.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
______ Under no circumstances will I engage in any illegal conduct, including, but not limited to, acts of battery and assault, shoplifting or the
destruction or damaging of the property of an individual or an entity.
______ Under no circumstances will I possess or use tobacco of any kind, illegal non-prescription drugs, or alcohol at any function.
______ I will maintain proper behavior with regard to interpersonal relations, including language and personal attire.
______ I will refrain from engaging in any inappropriate sexual behavior, including but not limited to actions, which may be perceived by
reasonable persons to be sexually harassing in nature.
______ I will observe Kashrut and Shabbat in accordance with the practices as defined by the Law and Standards Committee of the Rabbinical
Assembly.
______ If I am male, I will wear my kipah at all functions. If I am Bar Mitzvah, I will wear tallit and t'fillin when appropriate. If I am female I
understand I may do so if it is my custom.
______ I will attend the event in its entirety unless excused in advance by the Regional Youth Director. I understand that Shabbat (Friday
night and Saturday) must be attended in its entirety.
______ I will not enter a room or area designated or assigned for exclusive use by members of the opposite sex.
______ I will assume all responsibility for any damage to property that may be caused by my actions, intentional or not, including costs of
repair or replacement of said property.
______ I will use only approved USY transportation to, from, and during any USY event. I understand that no USYer may ride in a car driven
by a (USY or non-USY) high school student to, from, and during any Regional event.
______ I will reside only in my assigned housing and I will abide by the curfew.
______ I understand that only USYers registered for the event will be permitted to participate.
______ I will listen to and cooperate respectfully with staff and my host family at all times.
______ I will take part only in activities that are authorized by the Regional Youth Director and supervised by event staff or the Regional
Youth Director’s appointee.
OFFENSES WHICH WILL RESULT IN MY BEING SENT HOME /REMOVED FROM
REGIONAL OFFICE AND /OR BARRED FROM ATTENDING FUTURE REGIONAL/NATIONAL EVENTS
15.
16.
17.
______ I understand that my violating any of the commitments set forth below will result in disciplinary action which WILL include my being
sent home at my parents' expense (after Shabbat has ended); my suspension from one or more regional activities including, but not limited
to any Tzafon Kadima/USY event, for which I am eligible, leading up to and including the next Tzafon Regional event and/or my immediate
removal from any regional executive or extended board position in which I serve. These infractions include:
a. engaging in any illegal conduct, including, but not limited to, acts of battery and assault, shoplifting, destroying or damaging the
property of an individual or an entity.
b. possessing or using, illegal non-prescription drugs, or alcohol at any function.
c. engaging in any inappropriate sexual behavior, including but not limited to actions which may be perceived by reasonable
persons to be sexually harassing in nature.
______ If a USYer is apprehended for an infraction of the International Youth Commission's policy regarding drug and alcohol abuse or any
other criminal offense (including, but not limited to shoplifting) punishment for that offense will include suspension from International USY
events (including, but not limited to the International USY Convention and USY Summer Programs) for one year following the infraction. The
USYer’s region reserves the right to impose additional sanctions in connection with this or any other improper behavior, as it sees fit.
______ I understand that the Region reserves the right to search the room and belongings of any attendee if it has reasonable grounds to
believe that such a search is necessary to secure the health , safety and/or welfare of the program and/or its participants. The regional Youth
Director, in consultation with the Regional Youth Commissioner, reserves the right to enforce other rules relating to the integrity of the
Regional Youth Program and / or the health, safety or welfare of its participants.
DUE PROCESS
18.
19.
______ I understand that upon learning that I may have committed any of the infractions as set forth above, the Regional Youth Director, or
his/her designee will discuss such violations with me. I further understand, that for acts of misconduct as set forth in paragraph 15 above, my
parents will immediately be informed by telephone, if possible, (unless it is Shabbat, in which case, my parents will be notified immediately
thereafter).
______ I further understand that the Regional Youth Director, prior to determining the appropriate disciplinary action to take, will, if feasible,
confer with the Regional Youth Commission Chairman as well as an individual from the professional staff of the United Synagogue of
Conservative Judaism and/or a lay leader from the Board of Directors of the Empire Region. I also understand that the Regional Youth
Director will, in a timely fashion, inform my Chapter Advisor/Youth Director, and provide a letter explaining the code infraction and
disciplinary action taken to me, my Rabbi, Advisor/Youth Director, Youth Commission Chairman, and parents.
I have read, and agree to the above CODE OF CONDUCT.
______________________________
Signature of USY Member
____________________________
Signature of Parent
HEALTH HISTORY and PARENT QUESTIONNAIRE
THIS PAGE MUST BE FILLED OUT FOR ALL PARTICIPANTS AND RETURNED WITH THE APPLICATION.
Name ________________________________________________ Birth Date _________ Sex ___ Age ____ Grade ____
Parent or Guardian _____________________________________ Home __________________Cell
___________
If not available in an emergency, notify: Name _______________________________ Relationship ____________________
Home phone ( ___ ) ___________
Cell phone/business phone (
)
FAMILY MEDICAL/HOSPITAL INSURANCE CARRIER ___________________________________________________
Group # ______________________________________ Policy # ______________________________________
____
Please attach a photocopy of the front and back of your medical insurance card and prescription plan card
TO BEST CARE FOR YOUR CHILD, WE NEED YOU TO PROVIDE AS MUCH DETAIL AS POSSIBLE!
HEALTH HISTORY:
ALLERGIES:
DRUGS:
FOOD: ________
MEDICATIONS YOUR CHILD IS PRESENTLY TAKING
(INCLUDE DAILY MEDICATIONS, AS NEEDED MEDICATIONS,
HERBAL SUPPLEMENTS AND VITAMINS)
OTHER:_________
LIST REASON FOR TAKING MEDICATION:
NOTE: If your child will be on medication at convention – please enclose a note listing Medications and specific dosing
instructions. Medication will need to be sent in original proscribing containers. THANKS
Is your child recovering from addiction, eating disorders or psychological conditions?
Operations, hospitalizations, serious injuries or illnesses (specify and give date) _________________
Describe any circumstance that could result in a situation(s) not compatible with group living or any other possibility of problem
behavior. ________________________________________________________________________________________________
Are there any special family situations that we should be aware of? ___ Death
_____ Divorce
____ Recent separation
____ Serious illness ____ Other Please provide details:
Please list all doctors (and their specialty) that are currently participating in your child’s care:
_____________________________________________________________________________
IF THERE ARE ANY CHANGES OR ADJUSTMENTS IN MEDICATION, WE MUST BE NOTIFIED IMMEDIATELY!
AUTHORIZATION AND VERIFICATION (This box must be completed)
The above information and health history is correct and complete to the best of my knowledge. I acknowledge that failure to disclose any
medical information, treatment or medication, could result in my child being removed from the program and sent home from camp at
my expense. I, the parent or legal guardian, of the applicant, state that he/she is in good normal health, has no abnormal physical or
mental handicaps and has my permission to engage in all prescribed camp activities except as noted under restrictions or modifications
above or on the Physical Examination Form.
I hereby give my permission to the Regional Director and staff:
1. To provide ongoing health care.
2. To select medical personnel and to order X-rays, routine tests or treatments for my child.
3. In case of medical emergency, accident or a serious health problem where immediate treatment is deemed necessary, I give
permission to the physician selected by the Regional Youth Director or the person designated by the Region to hospitalize,
secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named above. In such case, every
effort will be made to contact the parent or guardian of the applicant.
I am aware that this form may be photocopied for use by medical caregivers.
Parent/ Guardian Signature _________________________________________Print Name _____________________________________ Date ________
Tzafon Kadima / USY MEDICATION FORM
This form authorizes USCJ staff to hold and to provide the participant with his/her
prescription medication as required.
USYer/Kadimanik's Name
Height _____
Weight________
Date of Birth
Gender Male ___ Female ___
Drug Allergies
MEDICATION NAME
DOSE IN
MILLIGRAMS/
& # OF PILLS
FRI
SAT
SUN
BREAKFAST
LUNCH
DINNER
BED TIME
“AS NEEDED”
MEDICATION
JUST LIST
I hereby notify USY/Kadima that I am (my child is) capable of self-administering the following medication/medical
treatment, and I authorize USY/Kadima to allow me (my child) to self-administer:
My child and I understand and agree to follow the instructions set forth in the letter on the reverse side.
I give permission to allow the staff to administer over the counter medication (Tylenol/Advil/Pepto/Benadryl).
Signature of Parent or Guardian
_____________________
Date
PLEASE NOTE – USY AND KADIMA MUST KNOW IN ADVANCE OF ANY
CHANGES IN MEDICATION.