Date Night

Medical and Insurance Information
Parent/Guardian Authorization and Medical Release Form
My child has permission to attend Dor Chadash events with CBI during the academic year of 2018-2019. I agree not to hold CBI and/or its agents liable for any accident, loss or theft that may occur during the course of this event. I give permission to the adult staff to transport my child to and from an off-site location during the course of this event for the purpose of the event. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the adult staff to hospitalize, secure proper treatment for and order injections, anesthesia or surgery for my child as named above. I recognize that I will be responsible for any costs incurred for this treatment.
Parent/Guardian Signature*
Special Medical or Dietary Needs/Specifications*
Medical Insurance Carrier*
Policy Holder's Name*
Policy/Group Number*
Emergency Contact Information
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact's Cell Phone Number*

Billing Information
Billing Name*
First Last
Billing Address*
Street Address Address Line 2 City State ZIP Code
Billing Email*
Billing Phone*
Date Night RSVP*
Price for Date Night is $15 per child attending
Price: $15.00 Quantity:
Please note that upon submission, you will be taken to PayPal's website in order to enter your credit card information.

General Information