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Teen Retreat Registration Form (Part 2 of 2)
November 3 - 5, 2017

Full Price: $250
Early Bird Price (paid in full before September 15): $200

The last day to register for this retreat is October 26th.

Spots are available on a first come first serve basis.

No refunds are available for cancellations.


Teen Full Names
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Consent Statements

Parental Consent and General Release Statement
I give permission to my child/ren to participate in all of Wilshire Boulevard Temple’s Religious School/Youth Group programs, activities and events and release Wilshire Boulevard Temple and its representatives from all liability arising out of my child/ren’s participation in such activities. I grant power to Wilshire Boulevard Temple to take photographs, movies, videos of my child/ren while my child/ren is/are participating in Wilshire Boulevard Temple activities and for Wilshire Boulevard Temple the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release Wilshire Boulevard Temple from all claims, demands, and liabilities whatsoever in connection with the above.
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Emergency Information and Care
I/we hereby give permission for the above named child/ren to be given emergency care as administered, authorized or directed by any adult person acting on behalf of Wilshire Boulevard Temple Religious Schools. Such care may include x-ray examination rendered to said minor/s under the provisions of the Medicine Practice Act; anesthetic, dental or surgical diagnosis or treatment or hospital care to be rendered to said minor/s by a dentist licensed under the provisions of the Dental Practice Act, all pursuant to Civil Code 25.8. I/we further agree to pay the cost of all such medical or dental services. It is understood that if time and circumstances reasonably permit, Wilshire Boulevard Temple Religious School personnel will try, but not be required, to communicate with me prior to such treatment.
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