Insurance & Medical Information: Insurance Carrier: Family Physician: Address of Physician:

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1 Devar Emet Messianic Synagogue & Outreach Camp HaDerekh 2017: Medical & Parental Release Form 7800 Niles Ave. Skokie, IL / (847) / info@demjo.org / One form may be done for the entire family as long as the following apply: 1. Parent/Guardian(s) and Minors all have the same address 2. All Minors have the same insurance carrier/information PART I: MEDICAL RELEASE FORM Parent/Guardian Information: First and Last Name of Parent/Guardian(s) Address City/Zip Home Phone Cell Phone #1 Cell Phone #2 Insurance & Medical Information: Insurance Carrier: Group: Family Physician: Member Number: Phone: Address of Physician: Other contact in case of emergency: (This should not be an adult previously listed on this form) Name: Relationship: Address: Home Phone: Cell Phone: TO WHOM IT MAY CONCERN: As the parent or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the following minor(s) in the event of a medical emergency, which in the opinion of the attending physician may endanger the life, cause disfigurement, physical impairment or undue discomfort if delayed. I also release Devar Emet Messianic Jewish Outreach, Devar Emet Messianic Synagogue, and other organizations and individuals involved of any liability for accidents incurred during Camp HaDerekh This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. Signed Date

2 PART II: PARENTAL RELEASE FORM The signer of this document gives permission for their youth to attend and participate in Camp HaDerekh sponsored by Devar Emet Messianic Synagogue & Outreach. The signer of this document also agrees to allow camp leaders to drive their youth to and from the camp location (Camp Selah in Reading, MI). For camp activities that will require leaders to drive to outside locations, the signer of this document gives permission for their youth to ride in any vehicle designated by the adult in whose care the minor has been entrusted. After Camp HaDerekh is completed, the youth will be returned to Devar Emet Messianic Synagogue to await pick-up from the signer/other guardians or to their homes, if such arrangements have been made prior to the event with youth leaders and the signer/other guardians. The purpose of Camp HaDerekh is to take the youth up and away from their day-to-day activities and give them the opportunity to focus on deepening their relationship with G-d together with other Messianic Jewish youth like themselves. We believe the best way to allow youth to focus at our events is to remove all distractions, which includes television, secular music, computers, video games and cell phones. We therefore require that all electronic devices be left at home for this Camp HaDerekh. Any devices found at Camp will be confiscated, turned off and returned to parents when the youth return home. We believe this not only will enable the youth to learn better and think more deeply, but allow the start of developing healthy boundaries with technology. In case of an emergency, you can call Rachel Meiri s cell at (847) or Camp Selah home office directly at (517) and ask for Rachel Meiri. At Camp HaDerekh, the youth will also have the opportunity to do a wide range of activities. All necessary safety precautions will be taken, but some activities have higher risks than others. Activities at Camp HaDerekh may include but are not limited to: Hiking, fishing, archery, BB guns, capture the flag, banana boating, canoeing/kayaking, swimming, gaga ball, basketball, field activities, tie-dye, horseback riding. Additionally, please note that select pictures & video of activities may be used by Devar Emet Messianic Jewish Outreach & Devar Emet Messianic Synagogue for promotional purposes. As the parent or guardian, I do herewith authorize my youth to participate in all the above listed activities as well as any other activities that the Camp director and staff provide for my youth. I understand that all necessary safety precautions will be taken, and that any injuries that may take place during activities are not the fault of the camp staff. I also release and agree to hold harmless Devar Emet Messianic Jewish Outreach, Devar Emet Messianic Synagogue, and other organizations and individuals involved of any liability for accidents, damages or obligations incurred during any of the 2017 Camp HaDerekh activities. I also consent to having my youth leave their technology at home for the week of camp and understand I can contact Rachel Meiri if necessary to reach my child. Name (printed) Signed Date Questions can be directed to: Rachel Meiri or info@haderekhyouth.com. This activity is sponsored by Devar Emet Messianic Synagogue & Outreach, a Community of Jews who believe and teach that Yeshua (Jesus) is the promised Jewish Messiah.

3 CHILD #1 if yes, please explain: X

4 CHILD #2 if yes, please explain: X

5 CHILD #3 if yes, please explain: X Form Updated 8/15/16 Received Date: / / Received By:

Insurance & Medical Information: Insurance Carrier: Family Physician: Address of Physician:

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