Madrichim Application - Form - Congregation Beth Am

DUE DATE: August 1, 2019 for Sunday Program, Hagigah, Hebrew Program. Assignments will be given on a first come first serve basis. Please complete this form. When you have completed this form you will hear from the Beth Am Madrichim Coordinator to set up an interview. Please note: We are no longer accepting madrichim for Camp Beth Am for June 17-21, 2019.

* First Name

* Last Name

* Email Address

Home Telephone

* Mobile Telephone

* Best way to contact you

* Mailing Address

* City

* State

* Zip

* What grade will you be entering in Fall 2019?

* School Attending

* T-Shirt Size (Adult)

Number of Parents/Guardians on this account

* Parent/Guardian 1 - First Name

* Parent/Guardian 1 - Last Name

* Parent/Guardian 1 - Email

* Parent/Guardian 1 - Home Phone

* Parent/Guardian 1 - Work Phone

* Parent/Guardian 1 - Cell Phone

* Does Parent/Guardian 1 live at the same address as the student?

* Mailing Address

* City

* State

* Zip

Parent/Guardian 2 - First Name

Parent/Guardian 2 - Last Name

Parent/Guardian 2 - Email

* Parent/Guardian 2 - Home Phone

* Parent/Guardian 2 - Work Phone

* Parent/Guardian 2 - Cell Phone

* Does Parent/Guardian 2 live at the same address?

* Mailing Address

* City

* State

* Zip

* Have you worked as a madrich/a before?

Please list the programs and teachers you have worked with previously

* I am interested in:

Being Paid. I promise to return my completed forms (work permit I-9 W2 etc.) to Beth Am before the start of the programs.Being a volunteer and working for community service hours.

* Are there any other programs/times you are interest in?

If you wish to work in our Sunday Program please select the area you are interested in working in.

* Please select an option

* How comfortable are you with the Hebrew language?

* Please list any preference for teachers you wish to work with:

* Additionally I am interested in:

being on the Beth Am Babysitting List for Beth Am programs requesting sitters.being on the Beth Am Babysitting List for parent requests.being on the Madrichim Substitute list.I would prefer not to sub

* I am available to substitute:

Wednesday Hebrew 345 - 615pm Sunday Morning Hebrew 900 - 1115amSunday Afternoon Hebrew 1145 - 115pmSunday Program 845 - 1145amHagigah Theatre Program 345 - 615pm - WednesdayI would prefer not to sub

* Why do you want to become part of the Madrichim program?

* What are you doing to further your personal Jewish education this year?

* What other activities are you planning to do in your secular life this year?

Physician Name

Physician Telephone

Insurance Company Name

Plan/Group #

Policy #

Should my child become ill and a parent cannot be reached, please notify either of the following people. Also, should a civil defense emergency or natural disaster such as an earthquake occur, and I am unable to reach Congregation Beth Am to pick up my child, by selecting the appropriate items below, I designate the above person(s) to pick up my child.

* Contact 1 - Name

* Contact 1 - Relationship

* Contact 1 - Phone #

* Contact 1 - Ok to pickup

Contact 2 - Name

Contact 2 - Relationship

Contact 2 - Phone #

Contact 2 - Ok to pickup

* Does your child have any drug allergies?

Please list all drug allergies:

* Does your child have a history of any medical issues, such as astthma, diabetes, allergies, hearing difficulties, etc.?

Please list history here:

* Is your child presently taking medication on a continuing basis?

Please list medications here:

Prescribed for what condition(s):

* Does your child carry any medication with them?

Please list medications here:

What is their medication schedule?

* Are there any medications or medical supplies that we should store for your child in the Education office?

If yes, which medications or supplies? Please list medications and the situations in which they should be used. Medications should be hand delivered to the Youth Education office. All medications or supplies must be clearly labeled with your name, your telephone number(s), your child's name, and a picture of your child.

* Is there anything else we should know about your child to help them in the unlikely event of an injury or accident?

What should we know?

Permission to Seek Treatment

In the case of injury to, or illness of, a child while at Congregation Beth Am or on a retreat or other off-site activity, every effort will be made to contact the parent(s) or guardian. If a representative of Beth Am is unable to reach such person, the following instruction will remain in force unless revoked by the parent or guardian:

I hereby authorize Congregation Beth Am or any authorized representative to call my child's physician or dentist (or another physician or dentist available) for necessary care for my child in case of emergency. I agree to pay all expenses incurred. These authorizations shall remain effective from June 1, 2019 to June 30, 2020.

In addition, I do hereby authorize a representative(s) of Congregation Beth Am as agent (s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnoses or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the California Medical Practice Act, whether such examination, diagnoses or treatment is rendered at the office of said physician or at a government licensed hospital.

It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment, or hospital care being required, and is given to provide authority and power on any and all such examinations, diagnoses, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable.

This authorization is given pursuant to the provisions of California Family Code 6910.

* Parent Initals

Due date for this application is August 1, 2019 for our Sunday Program, Hagigah and Hebrew Programs. Assignments will be given on a first come first serve basis. Once you have submitted this form you will hear from the Beth Am Madrichim Coordinator to setup an interview. Please click here to review our Madrichim Agreement and then sign below.

* Student Signature

* Date