Socal Teen Retreat 2023 TILB

SoCal Teen Retreat 2023- TILB Only

In partnership with the Jewish Community Foundation Orange County, the Reform synagogues of Orange County and Long Beach are pleased to offer a 8th-12th Grade Teen Retreat on April 14th-16th, 2023 at the Irvine Ranch Outdoor Education Center, located in the city of Orange.

The Teen Retreat will begin on Friday, April 14th at 5:00 PM and will end on Sunday, April 16th at 12:00 PM.

Early Bird Pricing (until March 15th): Cost is $300 for each teen (You'll receive a $75 scholarship from TILB towards the $300)
Regular Pricing (begins on March 16th-April 6th): Cost is $350 for each teen (You'll receive a $75 scholarship from TILB towards the $350)

To read our FAQs for the retreat, please click here. If you have any further questions about registration, please reach out to Matt Ghan, our Retreat Director, at socalteenretreat@gmail.com.

Participant #1 Information

* Participant's Name

First Name

* Participant's Name

Last Name

Participant's Gender Identity

Female, Male, Non-Binary, Other

Does the participant identify as transgender?

NoYesPrefer not to disclose

* Participant Email

* Participant's Cell Phone Number

Phone Number

Participant's Birthday

Participant's Current Grade Level

Housing: Where do you prefer to be housed?

Choose OneMale IdentifyingFemale Identifying

Is there anything else we should know about your teen's gender identity, so that we can best support them at the retreat?

* Teen T-Shirt Size

* Parent/Guardian's Name

First Name

* Parent/Guardian's Name

Last Name

Relationship to Participant

* Parent/Guardian Email

* Parent/Guardian's Cell Phone Number

Phone Number

Parent/Guardian's Address

Is your family a member of a URJ/Reform Movement Congregation?

If so, which congregation? (Name and City)

Emergency Contact- First and Last Name

This person is different than the parent/guardian listed above. We will always try to contact that person first.

Emergency Contact- Relationship to Participant

Emergency Contact- Cell Phone Number

What else should we know about the participant's allergies?

Does the participant carry an epi-pen?

When is the epi-pen needed?

Does the participant have any dietary restrictions?

Does the participant have any medical, physical, and/or mental health issues you would like us to know about?

Please list any prescription medications being taken, including dosage and reason for taking.

Is the participant covered by family medical/hospital insurance?

Plan Name/Carrier

Group Number

Policy Number

Carrier Address (if applicable)

Claims Phone Authorization Number

Co-Pay Amount

Name of Insured

Insured Relationship to Participant

Participant #2 Information

Participant's Name

First Name

Participant's Name

Last Name

Participant's Gender Identity

Female, Male, Non-Binary, Other

Does the participant identify as transgender?

NoYesPrefer not to disclose

Participant Email

Participant's Cell Phone Number

Phone Number

Participant's Birthday

Participant's Current Grade Level

Housing: Where do you prefer to be housed?

Choose OneMale IdentifyingFemale Identifying

Is there anything else we should know about your teen's gender identity, so that we can best support them at the retreat?

What else should we know about the participant's allergies?

Does the participant carry an epi-pen?

When is the epi-pen needed?

Does the participant have any dietary restrictions?

Does the participant have any medical, physical, and/or mental health issues you would like us to know about?

Please list any prescription medications being taken, including dosage and reason for taking.

Waiver: The undersigned acknowledges that an online signature will, for all purposes, be treated as an original.

Authorizations:
Participant's parent/guardian gives permission to Socal Teen Retreat to provide routine health care and seek emergency medical treatment including but not limited to ordering x-rays and routine tests. Participant's parent/guardian gives permission to Socal Teen Retreat to release any of participant's records necessary for insurance purposes.

In case of participant's medical emergency, the participant's parent/guardian hereby gives permission to the physical selected by Socal Teen Retreat to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for participant, as named above. Information may be printed/photocopied for access in an emergency involving participant.

Indemnification:
Except with the respect to the sole negligence of the Socal Teen Retreat and its employees, the undersigned participant's parent/guardian hereby release, discharge, and hold harmless Socal Teen Retreat and their employees for any and all claims, lawsuits, or other legal causes of action, which relate to the undersigned participant's participation in a Socal Teen Retreat, and the participant's travel to and from Socal Teen Retreat, such events and programs, and related activities.

When you see Socal Teen Retreat listed, please know that Congregation Shir Ha-Ma'alot holds the certificate of insurance and liability insurance for this event.

* Parent/Guardian Signature

The undersigned acknowledges that an original signature will, for all purposes, be treated as an original.

Terms and Conditions Agreement:
The below Terms and Conditions between Socal Teen Retreat and my child (hereafter "participant") represent the expectations and agreements in order to participate in a Socal Teen Retreat activity.

In the mutual interests of Socal Teen Retreat, the participant, and for the well-being of all participants at Socal Teen Retreat, I understand, respect and will observe the rules, regulations and policies of Socal Teen Retreat, which have been developed for the benefit of all participants including participants to strengthen the Socal Teen Retreat program and enhance the experience for all participants. As parent/guardian of participant, I agree to the implementation and enforcement of the following rules, regulations and policies for Socal Teen Retreat program.

Requirements for Acceptance to the Socal Teen Retreat:

I agree that the participant's participation in Socal Teen Retreat is not confirmed until explicit written verification is received from Socal Teen Retreat, which notice will usually come to participant and his/her/their family, including me, via email.
Each participant will need to do a two-step Covid safety protocol, which includes:
- A copy of their completed vaccination card (uploaded on this form).
- When each participant arrives, they will be taking a rapid test before being allowed onto the campus for the retreat.

Refund of Payment Policies:

All cancellations must be in writing. We will accept cancellations by email to Socal Teen Retreat. Refund will be process and returned within six weeks after the conclusion of the event.
Refunds will be given bases on the following schedule:
- A 90% refund will be given 21 day prior to event date.
- A 75% refund will be given 14 days prior to event date.
- A 50% refund will be given 8 days prior to event date.
- No refund will be given 7 or fewer days prior to event date with exception of a documented medical emergency in which case a 75% refund will be granted.
Refunds will not be made if participant has attended any portion of the Socal Teen Retreat. This covers circumstances, including but not limited to:
- participant's homesickenss
- participant's refusal ro inability to participate in the normal activities
Participant's violation of any rules, regulations, or policies of Socal Teen Retreat for which the participant has been provided notice. Please see the rules and regulations below. Furthermore, I understand I will be responsible for the cost of my participant leaving the program early due to violation of the rules.

Participant rules and regulations that teens must abide by for the Socal Teen Retreat:

Teens will not possess, consume, or distribute alcoholic beverages, other than that served by adult leadership for Jewish sacramental purposes, even if they are of legal drinking age.
Teens will not smoke, consume, or distribute tobacco products, including e-cigarettes, at any time during the event.
Teens will not possess, use or distribute any illegal drug or drug paraphernalia, including marijuana regardless of the legality in the hosting state.
Teen will not commit any illegal acts. Teens understand that vandalism, disturbing the peace, or other inappropriate behavior as determined by the adult leadership in accordance with the youth leadership will not be tolerated. Teens will have to pay for any damages that they cause.
Teens will not participate in any activities before, during or after events that could deemed as hazing, sexually harassing, demeaning, hurtful, or bullying. This includes in-person interactions, interactions over cell phone and email, and actions in online spaces including but not limited to, Facebook groups, Twitter, Instagram, and other forms of social media between events.
Teens will exercise proper consent, and agree to refrain from inappropriate sexual behavior.
Teens will understand that consent is only given when someone gives positive and verbal permission to a sexual activity with another person, and that all people in a sexual situation must feel comfortable saying an explicit "yes" or "no" of their own free will to stop the physical activity at any point.

* Parent/Guardian Signature

Number of Teen Participants

Please select the number of participants that will be attending this overnight teen retreat. Since this form is ONLY for TILB participants, TILB will be billing you separately.

Ralphs Re-enrollment Time!

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