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Name of Participant agreeing to these terms:

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Are you covered by medical/hospital insurance?

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Parent/Guardian Last Name

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Parent/Guardian Phone Number

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Name of Medication #1:

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Would you like to add additional medications?

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Dosage of Medication #3:

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Does this family member live at the same residence as the Primary Registrant?

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Departure Flight Time:

Departure Bus Company:

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Relationship to Participant

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Name of Insured:

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Dosage of Medication #1:

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Name of Parent/Guardian of Youth Participant:

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Arrival Flight Time:

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Policy Number:

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Departure Time from Bus Stop:

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Carrier/Plan Name:

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Arrival Flight Airline/Carrier:

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Departure Flight Airline/Carrier:

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Departure Time from Bus Station:

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Name of Parent/Guardian picking up youth from event:

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Please share any accommodations you will need to fully participate while at camp:

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Departure Time from Station:

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Would you like to add another medication?

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Full Legal Name (include middle name)

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Background Check Authorization

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Please select your planned travel method TO the event:

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Departure Flight Time:

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Arrival Bus Company:

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Arrival Time from Bus Stop:

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Arrival Flight Number:

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Optional Roommate Request:

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Administration Time for Medication #1:

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Departure Flight Airline/Carrier:

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Arrival Time from Station:

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Dosage of Medication #2:

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Departure Train Carrier:

Do you have any known allergies?

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Departure Train Carrier:

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Administration Time for Medication #2:

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Reason for Medication #1:

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Departure Time from Station:

Arrival Bus Company:

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Please provide travel plan and arrival time:

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Claims/Phone Authorization Number:

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Departure Flight Number:

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Please provide travel plan:

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Name of Parent/Guardian dropping youth off at event:

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Arrival Time to Station:

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Parent/Guardian First Name

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Departure Flight Number:

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Would you like to add an emergency contact different from the parent/guardian listed above?

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Phone Number of Parent/Guardian dropping youth off at event:

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Departure Bus Company:

Emergency Contact Relationship to You:

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Name of Parent/Guardian picking youth participant up from event:

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What are your pronouns?

_{For more information about pronouns,}_{click here}

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Arrival Time to Bus Station:

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Name of Participant agreeing to these terms:

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Name of Medication #2:

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I have read and understand the above Administration of Medications During URJ Youth Programs information. My child is authorized to self-administer and has been instructed in self-administration of this medication. The Union for Reform Judaism, URJ Camps, Immersives, and youth programs and its directors, employees, and agents shall not be liable for any injuries or illnesses resulting from the youth participant’s self-administration of this medication.

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Reason for Medication #2:

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Name of Parent/Guardian agreeing to these terms:

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If you need to add additional medications, please use the space below to share medication name, dosage, reason for taking, and administration time for each.

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Please select a housing type:

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Please provide travel plan:

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Administration Time for Medication #3:

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Phone Number of Parent/Guardian picking up youth from event:

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Name of Parent/Guardian dropping off youth participant at event:

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Former Last Names (if applicable)

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Arrival Flight Airline/Carrier:

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Arrival Train Carrier:

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Please select your planned travel method TO the event:

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Group Number:

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Name of Medication #3:

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Signature (please enter your full name)

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Arrival Flight Time:

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Reason for Medication #3:

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Will this participant be taking any medications during the program?

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Arrival Flight Number:

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Please select your planned travel method FROM the event:

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Please provide specifics and sensitivity on all allergies (e.g. which animals, what medicines, which fruits, etc.)

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Phone number of Parent/Guardian picking youth participant up from event:

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Phone Number of Parent/Guardian dropping off youth participant at event:

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Arrival Date

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Departure Date

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Please select the checkbox below to confirm your consent.

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