Darrison Family Shabbaton
Application & Information for Host Family

Kindly be advised that refunds will not be issued for cancellations made within 48 hours of the scheduled event

Today's Date * +

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number *

Email Address *

Date of Birth *

Failure to provide accurate and complete medical information may lead to exclusion from future ETTA events.

Primary Diagnosis *

Developmental Disability? *

Intellectual Disability? *

Other Medical Information *

MEDI-CAL Number *

MEDICARE # *

Private Insurance? *

Policy Number? *

Are you taking any medication? *

Name(s) and schedule *

Do you need any help taking this medication? *

In case of an emergency. * This number should preferably be one that would be answered on the Sabbath in case of emergency. *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

"DARRISON FAMILY SHABBATON APPLICATION & INFORMATION FOR HOST FAMILY"

Any known information concerning client’s likes

Any specific activities that client likes

Are there any foods your son/daughter is allergic to or should not eat? Please list.

Any dietary requirements? Allergies? Special conditions?

We, the undersigned (self, parent or guardian) of our SON/Daughter do hereby authorize/consent to any medical or dental diagnosis or treatment and care deemed necessary and proper and provided under the supervision of any duly licensed medical or dental practitioner. *

We hereby give permission to the host family and counselor to assist in taking medications. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or care being required, but is given as a precautionary measure to provide authority and power on the part of our aforesaid agents(s) to give specific consent to any and all such diagnosis, treatment, or care which they seem advisable. It is further understood that the aforesaid agent(s) will make every effort to contact the parent(s)/guardian(s) prior to authorizing such treatment. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

AUTHORIZATION FOR USE OF IMAGE, VOICE, PERFORMANCE, ARTWORK OR LIKENESS I permit and authorize ETTA Israel (herein referred to as “ETTA”) and its employees, agents, representatives, contractors, affiliates and personnel who are acting on behalf of ETTA to create and/or obtain and use my photograph, my voice or quotes/excerpts of my written or verbally expressed words, my artwork or a photograph of my artwork, my name, alias, or biographical information, a video and/or audio recording or other likeness of myself (hereinafter collectively referred to as "My Likeness") for purposes related to the mission of ETTA, including instructional and/or educational purposes, publicity, marketing, and promotion of ETTA and its various programs without compensation to me. I understand My Likeness may be copied/reproduced and distributed by means of various media, including, but not limited to, video presentations, simultaneous television broadcast/ rebroadcast, radio transmission/ re transmission, news releases, mail-outs, e-mails, billboards, signs, brochures, holiday cards, placement on websites and/or other electronic delivery, publication, display, or promotion on any and all other media, and I further understand that My Likeness may be subject to reasonable modification or editing. I acknowledge that ETTA and its affiliates have the right to make one or more photographs, audio recordings, videotape or disk presentations, or other electronic reproductions of My Likeness in accordance with this Authorization for Use of Image, Voice, Performance, Artwork, or Likeness (hereinafter sometimes referred to simply as "this Authorization"). I waive any right to inspect or approve the finished product or material in which ETTA may eventually use My Likeness. I relinquish and give ETTA and any of its affiliates all rights, title and interests in and to My Likeness, including any copyright therein. This Authorization shall be binding upon my heirs, successors, assigns, and legal representations. I understand that, although ETTA and its affiliates will endeavor to use My Likeness in accordance with standards of good judgment, ETTA cannot warrant or guarantee that any further dissemination of My Likeness will be subject to ETTA supervision or control. Accordingly, I release ETTA and its affiliated entities from any and all liability related to the dissemination, reproduction, distribution, and/or display of My Likeness in print or any and all other media, and any alteration, distortion or illusionary effect of My Likeness, whether intentional or otherwise, in connection with said use. This release allows ETTA to share photos with its affiliated entities. I also understand that I may not withdraw my permission for use of My Likeness which was granted in this Authorization. I have read and understand the conditions of this Authorization for Use of Image, Voice, Performance, Artwork, or Likeness. Please type your name below: *

Kindly be advised that refunds will not be issued for cancellations made within 48 hours of the scheduled event

Darrison Family Shabbaton Application & Information for Host Family

Kindly be advised that refunds will not be issued for cancellations made within 48 hours of the scheduled event

Failure to provide accurate and complete medical information may lead to exclusion from future ETTA events.

In case of an emergency. * This number should preferably be one that would be answered on the Sabbath in case of emergency. *

"DARRISON FAMILY SHABBATON APPLICATION & INFORMATION FOR HOST FAMILY"

Kindly be advised that refunds will not be issued for cancellations made within 48 hours of the scheduled event

Darrison Family Shabbaton
Application & Information for Host Family