TheTribe Medical Forms

Sweet! Thanks for submitting your RSVP to TheTribe Retreat. Please fill out the Medical Forms and Code of Conduct. Begin with the Medical Form and then complete the short Code of Conduct on the right hand side of this page.

TheTribe Medical Release Forms

STUDENT INFORMATION

* Indicates required field

Student Name *

First

Last

Student's Age *

Date of Birth *

Grade *

Gender *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone # *

Student Email *

PARENT INFORMATION

First Parent / Guardian Name *

First

Last

First Parent Email *

Home Phone Number *

Cell Phone Number *

Second Parent / Guardian Name *

First

Last

Second Parent Email *

Home Phone Number *

Cell Phone Number *

ADDITIONAL EMERGENCY CONTACT INFORMATION

Emergency Contact Name *

First

Last

Phone Number *

Health Insurance Company / ID # *

Medical Restrictions *

Allergies *

Dietary Restrictions *

Vegetarian Kosher Other

If you selected OTHER, explain *

EMERGENCY MEDICAL RELEASE INFORMATION: I hereby give my consent
for Main Line Reform Temple and designated staff, to make available to my child(ren) professional emergency medical care if such is indicated. It is understood that a conscientious effort will be made to notify the adults listed herein before such action is taken. However, in the event that this is not possible, I give permission for my child(ren) to receive medical care by any doctor, nurse, paramedic or member of a medical staff licensed by the state of Pennsylvania. This is to certify that my child is in good health. He/she has my permission to participate in all activities that are part of the regular program.

I hereby grant permission to the MLRT retreat staff to provide my child with the following medications, if necessary: (please check all that apply) *

If the student has any prescription that must be taken during the program, it must be in the original bottles clearly marked with student’s name, the name of the medication and dosage. All medication must be given to Ross M. Levy at the start of the retreat and it will be dispensed appropriately. Parent/Guardian must also indicate the necessity for the medication and the appropriate dosage either below on this form or in a note to Ross M. Levy.

Parent Digital Signature *

Signature

AFTER CLICKING SUBMIT PLEASE SCROLL TO THE TOP OF THE PAGE TO VERIFY THE CONFIRMATION OF YOUR SUBMISSION 

Submit

TheTribe Code of Conduct Form

I will promote the creation of a religious youth community based on mutual respect and a sense of personal well being. I have read the following rules, designed to promote health and safety of all event participants, and have indicated my unqualified acceptance by my signature and that of my parent/guardian.

I will not overuse my cell phone for weekend tris. I understand that the if I do, as deemed by the staff, the phone will be held by staff until the conclusion of the weekend.
I will not possess, consume, or distribute alcoholic beverages, other that that served by adult leadership for Jewish sacramental purposes, even if I am of legal drinking age.
I will not possess, use, or distribute any illegal drug or drug paraphernalia.
I will not smoke or consume or distribute tobacco products.
I will attend and participate fully in the entire event, unless otherwise agreed upon with Retreat Staff. I will attend on time, stay until the end, and remain on the event premises at all times.
I will not commit any illegal act. I understand that vandalism, disturbing the peace, or other inappropriate behavior, as determined by the adult leadership will not be tolerated. I understand that I will have to pay for any damage that I cause. I understand that no gambling is allowed, except for fund-raisers approved by the adult leadership.
I will abide by the event curfew announced by the leadership. After each event session, I will go directly to my living area and remain there until breakfast the following morning.
I understand that no guests are allowed at any retreat weekend, unless permission is granted in advance by adult leadership, and that any unauthorized guests will be asked to leave immediately.
I agree to refrain from inappropriate sexual behavior.
I will not possess, use or distribute weapons of any kind (i.e. knives or guns).
I agree to abide by any additional rules, pertinent to a specific event, which may be announced, and to accept the consequence of their violation.

I understand that these rules of behavior apply from the time I leave home for the event, during the event itself, and until I return home after the weekend retreat or trip. This applies to all programs that are part of the MLRT TheTribe Program.

* Indicates required field

Name *

First

Last

FOR STUDENTS ONLY: By clicking this option you agree to adhere to the rules and regulations stated in the above contract. *

I agree

Name *

First

Last

FOR PARENT ONLY: We have read the preceding rules, and fully understand them. We understand that sanctions imposed by the weekend retreat supervisor for violation could include immediate expulsion from the event, at the expense of the parent or guardian. Any student who is required to leave a retreat or trip due to disciplinary problems will be required to be picked up at the retreat site by the student’s parents/guardians. *

I agree

SUBMIT CODE OF CONDUCT

Sweet! Thanks for submitting your RSVP to TheTribe Retreat. Please fill out the Medical Forms and Code of Conduct. Begin with the Medical Form and then complete the short Code of Conduct on the right hand side of this page.

TheTribe Medical Release Forms

STUDENT INFORMATION

PARENT INFORMATION

ADDITIONAL EMERGENCY CONTACT INFORMATION

TheTribe Code of Conduct Form

FOR QUESTIONS OR COMMENTS PLEASE CONTACT RABBI NEWBURGE or ROSS M. LEVY