Name: 9th Grade Sexuality & Healthy Relationships Retreat
Start: 2026-01-23T00:00:00-05:00
End: 2026-01-25T23:59:59-05:00
Location: Non-WHC Site

PROGRAM INFORMATION

A separate form must be submitted for each student attending.

For questions about this form, please contact Leila Gordon at lgordon@whctemple.org.

PARENT INFORMATION

Parent's First Name

Parent's Last Name

Parent's Email Address

Parent's Phone Number

EMERGENCY CONTACT INFORMATION

This information will be used in the event we cannot reach one of the parents listed above.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

BUS TRANSPORTATION

My child will board the bus at:

Temple (4:00 pm) JBSC (4:45pm)

MEDICATION & ALLERGIES

If other, please specify:

Note: Without your permission, we are unable to give any of the medications listed above to your child.

In the space below please list any allergies your child has, food or otherwise. If none, please write N/A.

HEALTH INSURANCE INFORMATION

Health Insurance Company

Health Insurance Policy Number

STUDENT CODE OF CONDUCT FOR WHC RETREATS

1. I will attend and participate fully in the retreat, including arriving on time, remaining on the premises throughout and staying until the end, unless agreed upon ahead of time in writing with the staff in charge.

2. I will abide by the curfew announced each night by the staff.

3. I understand that cabins are private spaces and are only for those who have been assigned to them. Students should NOT be in a cabin that they are not assigned to.

4. I will treat others with kindness and respect. I will not participate in any activities that could be deemed as hazing, sexually harassing, demeaning, hurtful or bullying. This includes in person as well as interactions over cell phones and/or social media.

5. I agree to refrain from inappropriate sexual behavior and exercise proper consent. If I hear of, or see, any act of sexual misconduct, I will report it immediately to a trusted adult.

6. I agree not to photograph or make video recordings of anyone without their express permission and not to take photographs or videos in inappropriate places such as restrooms or changing areas.

7. I agree not to possess, consume or distribute any alcoholic beverages, tobacco products, drugs or drug paraphernalia at any time.

8. I will not possess or use any weapons or anything that might be construed as a weapon.

9. I will not commit any illegal act, including vandalism, or other inappropriate behavior and I understand that I will have to pay for any damage that I may cause, even if inadvertently.

FOR STUDENT SIGNATURE:

I understand the rules and expectations that are being asked of me in order to participate in the Washington Hebrew Congregation retreat being held January 23-January 26, 2026. I agree to abide by these rules and the instructions of the counselors and staff. I agree to help create a positive environment for all participants. I further understand that if I am unable to follow the rules and procedures for this weekend that I will need to leave the retreat.

I understand WHC's Code of Conduct for retreats and agree to abide by all the rules listed above.

Student Name

Date

FOR PARENT/GUARDIAN SIGNATURE:

I give my permission for my child (named above) to participate in the Washington Hebrew Congregation retreat being held January 23-January 26, 2026. I also agree to allow them to be transported by charter bus to and from the retreat center. I agree to indemnify and hold harmless the staff and volunteers of Washington Hebrew Congregation for any harm which may come to my child while participating in this program. I understand the rules and policies of the retreat for my child. I also understand that if my child does not adhere to these rules I will be asked to come pick them up right away.

I understand WHC's Code of Conduct for retreats and understand that my child my follow all of the rules listed above.

Parent/Guardian Name

Date

TOTAL COST

Subtotal

Admin Code (Staff Use Only)

Enter Admin Code

Amount Due Today

Would you like to make a donation? Enter the amount below. Donations to the Lewis S. Wiener Annual Fund support the Temple's greatest financial need.

This donation is from:

Total Amount

Refund policy

PAYMENT METHOD

How would you like to pay your bill?

Credit Card (includes 3% fee)ACH (Direct Bank Debit - No fee)

CREDIT CARD INFORMATION

To help defray some of WHC's credit card processing costs, a 3% fee has been added to your credit card payment. Please note that ACH payments do not include this fee.

Fee Amount

Grand Total

First Name on Card

Last Name on Card

Credit Card Number

Expiration Month

Expiration Year

CVV

Billing Street

Billing City

Billing State

Billing Zip Code

ACH INFORMATION

Personal check with labels for routing and account numbers

Bank Routing Number

Bank Account Number

Bank Account Type

CheckingSavings

Bank Name

Account Holder's Name (NOTE: If this is a joint account, use one name only. If it's a trust/foundation use one first/last name only)

Billing Street

Billing City

Billing State

Billing Zip Code

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Account ID

Contact ID

Outreach/Event Pre-Fill

OutreachID

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Auth.net Connector Billing Info

Gateway Address

Gateway City

Gateway State

Gateway Zip

Gateway Totals

Gateway Quantity

Gateway Amount

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Start:	Friday, January 23
End:	January 25, 2026
Venue	Non-WHC Site
Tags	Religious School
Organizer	Leila Gordon

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Events Calendar

9th Grade Sexuality & Healthy Relationships Retreat

January 23, 2026 - January 25, 2026

Non-WHC Site

2026 Sexuality & Healthy Relationships Retreat

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