HBTeen Montreal Trip

HBTeen Montreal Trip

Hosted by Holy Blossom Temple

November 8 - November 10, 2024

Grades: 8 & 9

$600 per person

Participant Information

Pronouns

Please specify

First Name

Last Name

Why are we asking for pronouns? https://urj.org/quick-guide-pronouns

Gender

Grade

Email address

Cell

Parent Information

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent/Guardian 1 Email Address

Parent/Guardian 1 cell number

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Email Address

Parent/Guardiann 2 cell number

Medical Information

All known confirmed allergies (if none, mark n/a):

If allergies are life threatening, please explain the symptoms and the treatment:

Medications (if none, mark n/a):

Please add any additional medical information that we should be aware of below

Emergency Contact

Please provide an alternate contact to the parent/guardian information provided above.

Name

Relationship to participant

Cell number

Additional information

Please list any additional details below i.e. dietary restrictions or accessibility needs

Transportation & Medical Waiver and Release

I, the undersigned, give my consent for the student identified above to be transported by Holy Blossom Temple by coach bus and will assume all liability for their participation in this event and any injury that may result during the transport or at the event. Further, by signing below:

1. I will not hold Holy Blossom Temple, its officers, agents, employees, assigns or anyone acting on its behalf, responsible or liable for injury occurring to the named person in the course of such activities or such travel.

2. I hereby accept financial responsibility for personal items lost by the person identified herein.

3. I authorize Holy Blossom Temple to transport and to obtain, through a physician of its own choice, any emergency medical care that may become reasonably necessary for the person in the course of such activities/events or such travel, and agree to accept the cost of the transportation and/or treatment by medical personnel or facility.

4. I accept full responsibility and hereby grant permission for my minor child to travel with Holy Blossom Temple. This Waiver and Release will be valid for all transportation occurring as of and after the date below.

This Waiver and Release is valid through November 8 - 10, 2024

By typing my name and clicking the box, I agree to the above transportation and medical waiver.

Name of Parent/Guardian

Fee & Payment

Total Fee

Preferred Payment Method

Credit Card Information

First Name

Last Name

Billing Address

Billing City

Billing Province/State

Billing Postal/Zip Code

Billing address must match the address associated with the credit card.

Credit Card Number

Visa or Mastercard ONLY

Expiry Month

Expiry Year

E-transfer

Please note the following:

The HBT email address is payments@holyblossom.org
Please include the students name and HBTeen Montreal Trip in the e-transfer message details.

Yes! I would like to make a contribution to future programming at Holy Blossom Temple

Thank you! You will now be redirected to the Holy Blossom Temple website after registering. Please check your email for additional information.

Thank you! You will now be redirected to program donation form. Please check your email for confirmation of your registration.

Invoice Name

Authnet_Hidden_Fields

Final Contribution

Invoice req'd

YesNo

Contact Information