Gesher DC Trip 2024

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Register Below

Temple Anshe Hesed - Gesher DC Trip Registration 2024

The dates for this year's trip are April 11th-14th. Cost per student is $125.

Please sign into your Temple Account before completing the online registration. If you need assistance with this, please contact the Temple office at 814-454-2426.

Family Name

STUDENT INFORMATION

How many students are being registered?

STUDENT 1 INFORMATION

Student 1

Student 1 - Name

Student 1 - Date of Birth

Student 1 - Secular Grade

Student 1 - Secular School

Student 1 - Preferred Pronoun

(i.e. he, him, his, she, her, hers, they, them, theirs)

Student 1 - Allergies

Student 1 - Health Concerns

Student 1 - Special Needs

STUDENT 2 INFORMATION

Student 2

Student 2 - Name

Student 2 - Date of Birth

Student 2 - Secular Grade

Student 2 - Secular School

Student 2 - Preferred Pronoun

(i.e. he, him, his, she, her, hers, they, them, theirs)

Student 2 - Allergies

Student 2 - Health Concerns

Student 2 - Special Needs

PARENT INFORMATION

* Parent/Guardian 1 - First Name

* Parent/Guardian 1 - Last Name

* Parent/Guardian 1 - Email Address

* Parent/Guardian 1 - Cell Phone

* Parent/Guardian 1 - Address

* Parent/Guardian 1 - City

* Parent/Guardian 1 - State

* Parent/Guardian 1 - Zip Code

Parent/Guardian 1 - Home Phone

Is there a second Parent/Guardian?

* Parent/Guardian 2 - First Name

* Parent/Guardian 2 - Last Name

* Parent/Guardian 2 - Email Address

* Parent/Guardian 2 - Cell Phone

Does parent/Guardian 2 live at the same address as Parent/Guardian 1?

Parent/Guardian 2 - Address

Parent/Guardian 2 - City

Parent/Guardian 2 - State

Parent/Guardian 2 - Zip Code

Parent/Guardian 2 - Home Phone

MEDICAL INFORMATION

Physician Name:

Phone Number:

Insurance Company:

Policy / ID#:

EMERGENCY CONTACT INFORMATION

Please list two persons other than parents that can be contacted in the event of an emergency.

* Emergency Contact 1 - Name

* Emergency Contact 1 - Phone Number

* Emergency Contact 1 - Relationship to Student

Emergency Contact 1 - My child(ren) may be released to this person.

* Emergency Contact 2 - Name

* Emergency Contact 2 - Phone Number

* Emergency Contact 2 - Relationship to Student

Emergency Contact 2 - My child(ren) may be released to this person.

RELEASE INFORMATION

* Please check to confirm all boxes below:

Press Release: I grant the Gesher Program of Temple Anshe Hesed permission to take photographs / videos of my child(ren) in connection with Gesher School events. I agree that Temple Anshe Hesed Gesher Program may use this consent for such purposes as newsMedical Release: In the event of a medical emergency or injury, I authorize Temple Anshe Hesed to administer First Aid and/or transport for my child(ren)Activities Release: I authorize my child to participate in any trip activity, including added stops not on the itinerary without prior notice. I also release Temple Anshe Hesed to transport my child(ren) to the destination, all activities and home.

Total Fees

Sat, April 27 2024 19 Nisan 5784