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San Diego Regional CTeen Shabbaton Parent Consent Form
Teen’s Name:
Birth date: Cell Phone:

Address
Home Phone:

Parent/Guardian’s Name:

Parent/Guardian’s Work Phone: Cell Phone:
In case of emergency contact:
1) Name: Daytime Phone:
Relationship: Cell Phone:

2) Name: Daytime Phone:
Relationship: Cell Phone:

Name and phone number of primary treating physician:

Allergies (including medications teen can NOT take)/Special Health Concerns:

Authorization to Obtain Urgent or Emergency Medical Care
As the parent(s) or legal guardian(s) of (name of teen), I/we
give permission for CTeen, its agents, staff, and volunteers to obtain urgent or emergency
medical care for my/our child, and I/we authorize health care providers to render such care as
may be necessary. It is understood that reasonable efforts will be made to contact me/us prior
to obtaining such care, but I/we authorize such care whether I/we are contacted or not, and
I/we agree to be financially responsible for such care.
      Parent/Legal Guardian

Medical Insurance Company:

Policy/Group Number:

Participant ID Number:

Medical Insurance Phone Number:

Permission to Participate; Release, Waiver of Liability, and Indemnity Agreement
I/we give permission for (name of teen) to participate in the
activities and trips of CTeen’s San Diego Teen Shabbaton. In consideration of the opportunity of
my/our child to participate in the activities of CTeen’s  San Diego Teen Shabbaton, I/we release
CTeen, its officers, agents, employees, staff, and volunteers from any and all liability of any kind
whatsoever for any loss or injury to my/our child arising from my/our child’s participation in the
activities of the San Diego Teen Shabbaton; and I/we agree to indemnify and hold forever
harmless CTeen, its officers, agents, employees, staff, and volunteers from any and all liability
of any kind whatsoever for loss or injury to my/our child arising from activities of the Teen
Shabbaton or resulting from traveling to or from the activities.
            
Parent/Legal Guardian                                                                 

Photo Permission
I/we understand that my/our child may be included in photographs and video footage that may be
filmed during the trip. I authorize CTeen to use these photos/videos to promote its programs and
services in print, web, and other promotional contexts.
              

Parent/Legal Guardian