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Madrichim Application

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.






























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.








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.

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.

Thu, November 14 2019 16 Cheshvan 5780