Student Phone Number*

High School*

Allergies/Dietary Restrictions (Please Note: All food served is certified kosher under the Star-K by our Mashgiach Gavi Ress)

Do you currently know any students at Cornell? If so, who?

Emergency Contact (Full Name)*

Emergency Contact Phone Number*

When will you be arriving? (If you don't know yet, that's fine!)

What are you planning on studying?

SHABBATON WAIVER: I hereby give my child permission to visit Cornell University (hereafter referred to as Cornell), on the previously listed dates on the Cornell Center for Jewish Living Shabbaton (hereafter referred to as the CJL). I understand that as a visitor to Cornell, my child will be expected to exercise judgment as to participation in the many educational, recreational, and social activities that are available and to assume full responsibility for the conduct during the visit. I understand that my child’s responsibilities are as follows: 1) Communicate by telephone with the designated student host 2) To bring a sleeping bag, toiletries, and other travel items necessary for an overnight visit. 3) To respect the host’s person, property, and time (especially sleep and study time) 4) To let the host know what facilities/activities he or she is interested in seeing 5) To be responsible for all conduct and decisions regarding program participation and social activities 6) To comply with all guidelines set by the CJL and to comply with all university, local, state, and federal laws and policies. 7) I understand that CJL and Cornell staff and student volunteers will not supervise or “chaperone” my child during this visit. I understand that my child will be on his/her own and that they are expected to follow the program set by the CJL. With full knowledge of the above and on behalf of myself, my child, my assigns, executors, and heirs, I hereby release, indemnify, and hold harmless the CJL, its trustees, officers, agents, and employees as well as Cornell University, its trustees, officers, agents, and employees from any and all liability, damage, claims of any nature whatsoever arising out of or in any way related to my child’s participation in this visit to Cornell. In spite of these facts, I have given my permission for my child to visit Cornell. If an accident occurs, I give my consent for emergency treatment. By signing below, I acknowledge I have read and fully understand all provisions of this Permission/Release Form.*

Child Signature*

Date*