Please read and sign our code of conduct. Thank you Code of Conduct No smoking is allowed. There is to be no possession or use of any narcotics, marijuana, other illegal drugs or prescription drugs not specifically prescribed for the user. There will be no possession or consumption of any alcoholic beverages. I will not shoplift or engage in any other type of illegal behavior. Any participant caught in possession of/or using alcohol or illegal drugs, will immediately be sent home at his/her parent’s expense. Participants are expected to maintain proper decorum and attitude during the entire program. Disruptive behavior (including, among other things, inappropriate sexual innuendo) will not be tolerated in any way shape or form. Your parents will be responsible to pay for any damage you may cause. No participant may leave the facility except at those times specified by the schedule. Each participant is expected to conduct him/herself appropriately as a Jew (including through the observance of Kashrut), in accordance with applicable standards of the trip organizers. The Uptown Chabad Chaperone, reserves the right to enforce other rules relating to the integrity of our Youth Programs and/or the health, safety or welfare of it’s participants. The Uptown Chabad Chaperone reserves the right to search the room and belongings of any participant if they believe that such a search is necessary to secure the health, safety and/or welfare of the program and or its participants. I have read these rules and understand them fully. I certify that I will adhere to this Code and will conduct myself in a manner reflecting credit upon my peers, my congregation, community and myself. I understand that any violation of this code of conduct may result in my being sent home at my parents' expense. The Uptown Chabad Chaperone has the sole discretion to send a participant home. I, the parent/guardian of, a minor, who will be participating in the CTeen International New York Retreat, do hereby certify that I have read the Code of Conduct set forth above. I do hereby agree that if my child who has signed the above Rules of Conduct fails to adhere to the Code, then in such an event those persons in charge of the program may send my child home at my expense. I understand that the Uptown Chabad Chaperone has the sole discretion to send my child home. PERMISSION TO TRAVEL Please let it be known that I, the undersigned, give permission for my child to travel to New York, New York USA with Rabbi Benny Kamchaji and The Chabad Israeli Group to the CTeen International Shabbaton. DISCLAIMER OF LIABILITY I have adequate medical coverage and insurance and give my child permission to attend The CTeen International New York Shabbaton and we (or I) agree to indemnify Chabad Israeli and all its officers, coaches and members for any claim which may hereafter be presented by our (or my) child as a result of any such injuries. Statement and Emergency Authorization: I (the parent or legal guardian) of the applicant state that he/she is in good/normal health, has no physical or mental handicaps that would interfere with full participation in the program and has my permission to engage in all available activities except as noted under Restrictions or Modifications above. I have been made aware of the fact that the events in which the likeness of my child is participating may be photographed by either amateur or professional photographers, and that the photographs may be used for purposes of reporting on the event, future publications or promotional material use as Uptown Chabad may determine. It is my understanding that by signing this document I consent to the use of the pictures just referred to for any purpose whatsoever. In case of a medical emergency, accident or health problem where immediate treatment is deemed necessary, every effort will be made to expeditiously contact the parent(s) or guardian(s) of the participant, or the emergency contact person listed above. In the event I cannot be reached, I hereby give permission to the physician selected by The Uptown Chabad Chaperone, or his/her designee, to hospitalize, secure proper and ongoing treatment and to order injection, anesthesia, or surgery for my child as named above. I fully agree to assume any financial responsibilities that may result from the aforementioned decision taken by the aforementioned individuals. I am aware that this form may be photocopied for use by medical caregivers. Full Name First Name Last Name E-mail Emergency Contact First Name Last Name Phone Number Payment includes the following: 1. Round trip coach bus (Thursday Morning - Monday Morning) 2. Two kosher meals and snacks in each direction 3. Supervised Accommodations in Brooklyn (rentals, AirBnB in Jewish Area) 4. Snacks, Food and Drinks for the apartments 5. Chaperons for the entirety of the trip Payment Subsidized Payment- $299Full Unsubsidized Payment- $499 Total $0.00 Payment Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2024202520262027202820292030203120322033 Expiration YearBilling Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Submit Should be Empty: This page uses TLS encryption to keep your data secure.