Ranch Day Application

TO COMPLETE YOUR RESERVATION, PLEASE COMPLETE THIS FORM

    Family Name*
    Mother*
    Father*
    Address*
    City*
    State*
    Zip*

    Email*
    Telephone*
    Synagogue*

    Transportation*

    Number of Adults Attending*
    Number of Children Attending*

    Child Attending:
    First Name
    Date of Birth
    Gender MaleFemale


    Child Attending:
    First Name
    Date of Birth
    Gender MaleFemale

    Child Attending:
    First Name
    Date of Birth
    Gender MaleFemale

    Child Attending:
    First Name
    Date of Birth
    Gender MaleFemale

    Child Attending:
    First Name
    Date of Birth
    Gender MaleFemale

    Child Attending:
    First Name
    Date of Birth
    Gender MaleFemale

    The following must be read and signed by a parent or legal guardian for everyone 18 and under:
    Consent To Treatment of Minor Pursuant To Family Code Section 6910
    I am the parent or legal guardian of the above minor child(ren), born on the dates listed above and consent to them engaging in all activities as set out herein and to travel by bus. I authorize Sephardic Tradition And Recreation staff to consent, in my absence, to x-ray, examination, anesthetic, medical, dental, surgical, diagnosis and/or treatment and hospital care for my child(ren) under the supervision and advice of a physician licensed under the Medical Practice Act and/or a dentist licensed under the Dental Practice Act. This authorization is effective November 15th, 2015.
    YesNo
    Date

    Name(s)of Parent(s) Responsible for Child(ren)
    What is the best phone number to call during this event, (if different from above)

    Student’s Doctor’s Name*
    Doctor’s Phone

    In the event I cannot be reached in an emergency, please notify:
    Name
    Relationship
    Phone
    Cell Phone


    * Required