Teen Los Angeles Trip

7th & 8th Grader Los Angeles Trip
PARTICIPANT REGISTRATION FORM

Registration is now open for our annual 7th grade trip to Los Angeles is coming, and we want your teen to be a part of all the fun! This trip will be packed with adventure, learning, and unforgettable memories that your teen will remember forever. Highlights include:

Visiting the Museum of Tolerance
Exploring the vibrant local Jewish community
Learning about Beit T'Shuvah, a local Jewish addiction treatment center
Noshing on delicious Jewish deli food
Spending a day with friends at Disneyland
Discovering diverse California-based Jewish organizations and communities
Building friendships to last a lifetime
And so much more!

It’s going to be an epic journey your teen will never forget!

Please read and complete each section carefully and submit by January 9, 2025. Please note that cost should never be a barrier to participating. Please contact Jacob Hershman at youthdirector@rodefsholom.org with questions or to learn more about available scholarship opportunities.

Details:

$875 per student for members of Rodef Sholom
$975 per student for non-members of Rodef Sholom
The fee per student covers ground related travel, meals, activities and accommodation throughout the trip.
Flights must be purchased separately by the parent/guardian: Southwest flight #2898 from OAK to LAX for January 30 and Southwest flight #3301 on February 2nd from LAX to OAK
Cancellations will be accepted up to January 9, minus a $50.00 processing fee.

If you have more than one student, please fill out separate forms for each.

Student Information

* Student Name

Student's Preferred Name

Student's Pronouns

Student Cell Phone

Please note: We require that any 7th and 8th grade registrant have a cell phone in order to attend the LA trip. If your student does not have a cell phone, please let Jacob know ASAP and we can work with you to determine the best solution.

Student Email

* Student Birthday

Parent or Guardian Information

* Parent/Guardian First Name

* Parent/Guardian Last Name

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

* Parent/Guardian Phone

* Parent/Guardian Email

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

* Address Line 1

Address Line 2

Address City

* Address State

* Address Zip Code

Please list the names of anyone your child would like to room with or attend this trip with (whether they have registered already or not). Please note we cannot guarantee these requests.

Emergency and Medical Information

* Emergency Contact Name

Emergency contacts must be someone other than the parent/guardian.

* Emergency Contact Relationship

* Emergency Contact Cell Phone

Second Emergency Contact Name

Second Emergency Contact Relationship

Second Emergency Contact Cell Phone

Please detail any allergies, dietary restrictions, or special accommodations for your child.

Does your student have any of the following medical conditions?

Physical ChallengesLearning DifferencesWears GlassesTakes medication every day

If you answered yes to any of the previous choices, please add a detailed explanation here.

* Medical Insurance Carrier

* Policy Holder Name

* Group/Policy Number

Parent's comments on student (personality, adjustments, experiences, likes, social development, physical development)

Congregation Rodef Sholom is dedicated to creating a safe and welcoming community. Please read carefully the following statements and provide a digital parent/guardian signature at the bottom.

* Health and Safety

Health and SafetyI give permission to Congregation Rodef Sholom to provide routine health care and seek emergency medical treatment. In the event that I cannot be reached in an emergency, I give my permission to the physician selected by the adult staff to hospitalize, secure proper treatment for and order injections, anesthesia or surgery for my child. I recognize that I will be responsible for any costs incurred for this treatment.

* Transportation

TransportationI give permission for child to be driven to and from the field trips or outings by approved vehicles (e.g. van, or automobile) providing transportation. I agree to indemnify and hold harmless Congregation Rodef Sholom, its employees, volunteers and the like from any harm which may come to participant while they are driving to or from, or being driven to or from, the field trips or outings.

* Indemnification

IndemnificationI hereby release, discharge, and hold harmless Congregation Rodef Sholom, its employees, and the like, from any and all claims, lawsuits, or other legal causes of action, which relate to the participant’s participation in programming, field trips, or the travel to and from the field trips.

* Full Name

By typing a name here, the student's guardian confirms that they read and understand the statements above and agree with all provisions contained here.

* Please choose an option below to give permission for Congregation Rodef Sholom to use my child(ren)’s photograph in publicity material, which may include internet postings, the Weekly bulletin, press releases and marketing materials.

Please Select OneI do give permissionI do not give permission

* Full Name as digital signature

The cost for this trip is $875 for members of Congregation Rodef Sholom, or $975 for non-members, per student. Flights are an additional cost and must be purchased separately. You will be able to pay securely by credit card or ACH transfer on the next page. To pay by phone, please call our office. For questions about payment please contact Cheryl Lazar at 415.479.3441 or accounting@rodefsholom.org.

Registration for this trip will be complete when we receive payment, or arrangement for payment, is made with the CRS office.

Cost should not prohibit any of our kids from experiencing a Jewish education at Rodef Sholom. Please check the box below if your family is interested in receiving scholarship for the LA trip and a member of our staff will reach out to you.

Yes, contact me about scholarship opportunities

Payment

* Please select the payment option based on Membership Level

Total Due

Thursday, January 30, 2025 • 1 Sh'vat 5785

Register