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

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1 Devar Emet Messianic Synagogue & Outreach HaDerekh Youth Winter Aliyah: Medical & Parental Release Form Niles Skokie, IL / (847) / / 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. This authority is granted only after reasonable effort has been made to reach me. 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 the Winter Aliyah 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 the HaDerekh Youth Winter Aliyah sponsored by Devar Emet Messianic Synagogue & Outreach. The signer of this document also agrees to allow Winter Aliyah leaders to drive their youth to and from the Aliyah location (The Cove of Lake Geneva in Lake Geneva, WI). For Aliyah 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 the Aliyah 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 the Winter Aliyah 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 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 Winter Aliyah. Any devices found at the Aliyah 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 the Cove of Lake Geneva (the hotel) directly at (262) and ask for Rachel Meiri in Rm 417. At the Winter Aliyah, 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 the HaDerekh Youth Winter Aliyah may include but are not limited to: Outdoor winter walks, tubing, tobogganing, broomball, and swimming. 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 Aliyah 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 is not the fault of the Aliyah 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 2016 Winter Aliyah activities. I also consent to having my youth leave their technology at home for the Aliyah weekend and understand I can contact Rachel Meiri if necessary to reach my youth. Name (printed) Signed Date Questions can be directed to: Rachel Meiri or 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 11/18/15 Received Date: / / Received By:

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

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