In case of emergency, please call (other than parents/guardians):

Medical Release & Liability

I hereby grant permission for my child to participate in all Temple youth programs, activities and events and do release Congregation Shir Ha-Ma’alot and its representatives from all liability arising out of my child’s participation in such activity.

In addition, I, the undersigned parent/guardian of the above child, do further certify that my child is physically able to participate in such activity and hereby authorize Congregation Shir Ha-Ma’alot and its authorized representatives as agents for the undersigned, to consent to any x ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is to be rendered under the general or specific supervision of any licensed physician (under the provisions of the California Medicine Practice Act) or the staff of a licensed hospital, whether such diagnosis, examination or treatment is rendered at the office of the said physician, or at such hospital.

It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of our above named agents to give specific consent to any and all such examinations, diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. The authorization is given pursuant to the provisions of section 25.8 of the Civil Code of California.

By selecting Yes below and by enrolling your child(ren) in Camp SHM at Congregation Shir Ha-Ma'alot, you indicate your agreement to the above terms and conditions.