SAWCY Registration - Form

Student's Preferred Name

Student's date of birth

Student's Fall 2022 grade

6th7th8th

School

Student's cell phone number

Student's home phone number

Student's email address

Address

Address 2 (Apt., Bldg)

City

State

Zip Code

Parent #1 Name

Parent #2 Name

Parent #1 Preferred Phone

Parent #2 Preferred Phone

Parent #1 Secondary Phone

Parent #2 Secondary Phone

Parent #1 Email Address

Parent #2 Email Address

FOR PARENTS: Please add me/us to the RATSY Parents email list.

YesNo

Emergency Contact #1

Please include:
NAME, RELATIONSHIP, PRIMARY and SECONDARY PHONE NUMBERS

Emergency Contact #2

Please include:
NAME, RELATIONSHIP, PRIMARY and SECONDARY PHONE NUMBERS

Allergies and Other Medical Concerns

Date of Most Recent Tetanus Booster

Doctor's Name and Office Phone Number

Insurance Carrier, Subscriber Name, and Policy Number

I hereby grant permission for my child to be a member of Sinai Association of Way Cool Youth (SAWCY) and to participate in activities. This will serve to release Temple Sinai and all of its personnel, employees, and representatives from liability in case of accident or injury resulting from all causes in connection with such membership, including outings, field trips or other activities which necessitate travel away from the Temple, except employees and representatives.

YesNo

In granting this permission and release, I specifically recognize that my child may be transported to SAWCY events by private vehicles operated by employees, or representatives of Temple Sinai. In such regard I release and will hold harmless Temple Sinai, SAWCY, employees, agents, and representatives from any and all liability which may arise as a result of such transportation whether or not organized by SAWCY. [SELECT ALL THAT APPLY]

I grant permission to attend RATSY-sponsored events in a bus.I grant permission to attend RATSY-sponsored events in transportation provided by an adult aged 21 or older.I grant permission to attend RATSY-sponsored events in transportation provided by a teenaged driver.

I empower Temple Sinai of Rochester to act for me in accordance with their best judgment in case of an emergency. My child is in good physical health and does not have any conditions which may be aggravated, except as noted on the application form.

YesNo