Yachad Midwest Shabbaton 2024

Yachad Shabbaton 2024

Thank you for registering for the 5th Hartman Family Foundation Yachad Midwest Family Shabbaton.

We look forward to spending a wonderful weekend together.

The hotel is located at 2111 Butterfield Rd., Downers Grove, IL 60515. Please be on time for our signature lunch buffet, available at 2:00pm upon completion of your registration / check-in. In the meantime, please contact me at cohene@ou.org should you have any questions.

5th Biennial Hartman Family Foundation Yachad Midwest Family Shabbaton
March 8-10, 2019
Doubletree Suites by Hilton Hotel & Conference Center
2111 Butterfield Rd.
Downers Grove, IL 60515

If you would like to apply for a scholarship, please contact Elliot Cohen before filling out this application at CohenE@ou.org or 844-4-YACHAD (844-492-2423).

* indicates required fields

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PARENT/ GUARDIAN INFORMATION (ONLY THOSE ATTENDING)

* At least one Parent/Guardian information is required.

Father/Guardian First Name:

Father/Guardian Last Name:

Father/Guardian Email:

Father/Guardian Cell #:

Father/Guardian Home #:

Father/Guardian Food Allergy:

Mother/Guardian First Name:

Mother/Guardian Last Name:

Mother/Guardian Email:

Mother/Guardian Cell #:

Mother/Guardian Home #:

Mother/Guardian Food Allergy:

Address: *

City: *

State: *

Zip Code: *

Please List all Non Married Children (Including Members) Attending:

Due to overwhelming request, Yachad will once again be running a series of programs and workshops for children of all ages.
Siblings are welcome and encouraged to attend.

Name: *	Age: *	Disability:	Food Allergies:	Gender: *
		Yes		Male Female

MARRIED CHILDREN OR OTHER FAMILY ATTENDING

First Name:

Last Name:

Age:

Food Allergy:

Spouse First Name:

Spouse Last Name:

Spouse Age:

Food Allergy:

Relationship (to individual with disability)

Email:

Phone #:

Cell #:

Current address (if different than above):

City:

State:

Zip Code:

Please list children attending with "other relative":

Name:	Age:	Disability:	Food Allergies:	Gender:
		Yes		Male Female

CHILD / ADULT WITH DISABILITY INFORMATION

First Name: *

Last Name: *

Birthdate: *

Age: *

Where will your family member be sleeping on the Shabbaton? *
* All family members under the age of 8 MUST room with family

In a room with Yachad advisor/peers

With parents, or a family member

Does your child have any Allergies? *

Yes

If Yes, Please Specify:

Does your child take medication? *

Yes

Who will administer medication?

Self

Family

Medication

While the responsibility to administer medication will be on the family over the weekend, the following information is required for us to ensure a safe and smooth Shabbaton.

NAME:
(specific name of the medication)

TIME GIVEN:

Morning	Afternoon	Evening

DOSAGE:
(amount of)

DESCRIPTION:
(Size, Shape, Color)

PURPOSE:
(why medication is given)

Procedure to follow if medication is missed

Please check off all that applies to your child in order to help our staff work with him or her throughout the weekend:

Does your family member have a seizure discorder? *

Yes
No

How often do the seizures typically occur?

Daily
Weekly
Monthly
Controlled by medication

What was the date of their last seizure?

Does your family member have any auras?

Yes
No

Describe type, duration, characteristics, known triggers, etc

Does your family member use Vagus Nerve Stimulation (VNS)?

Yes
No

Are there any warning signs of impending medical crisis we should be aware of? *

Yes
No

Describe

Do you give permission to Yachad staff or volunteers to administer Tylenol (acetaminophen) and Advil (ibuprofen) over the counter to your family member? *

Yes
No

Please check off all that applies to your child in order to help our staff work with him or her throughout the weekend:

Needs assistance getting dressed

Needs assistance eating

Needs help with physical activity

Needs assistance with grooming

Uses a mobility device

Other assistance

The following techniques are helpful in working with my child (i.e. support with transitions, positive reinforcements, visual cues, behavior modification plan):

I would like the staff to consult me if the following issues/situations arise:

Is there any other helpful information you would like to share with us in order to ensure the success of the shabbaton:

ROOMING REGISTRATION

PLEASE FILL OUT ACCORDING TO HOW MANY ROOMS YOU WILL BE OCCUPYING
Please note: your first room is included in your registration fee. Any additional rooms will be an added $200 fee ($100/night).
*Yachad will try its best to accommodate requests, but cannot guarantee them

Room {{ (index + 1) }}

King Room

Queen Room

No Preference

**PLEASE NOTE: King room = one king bed, one sofa-bed (full-size mattress) and the ability to add one roll-away / inflatable mattress; capacity 5 people. Queen room = two queen beds, one sofa-bed (full-size mattress); capacity 6 people. One crib may be added to each room. No exceptions per hotel policy! Rooms will be assigned at discretion of Yachad, and king/queen rooms may be reassigned due to quantity limitations.

Names of people staying in the room:

If you have a Yachad member in your family, and would like him/her to stay with an advisor (ages 15 & over), do not list that child in this space.

Please check if you will need the following:

Crib - no charge (limit 1 per room)

Extra Mattress

$25/night for an extra mattress (King rooms only; Queen room add-on not eligible due to fire code)
A limited amount of cribs and extra mattresses are available and will be assigned on a first-come, first-served basis.
Refrigerators in all rooms.

Additional rooming requests:

MEAL SEATING

If you have a request for whom you would like to sit with at meals, Yachad will try its best to honor those requests for at least ONE of the Shabbat meals.

All family members are seated together for Shabbat Dinner. For Shabbat lunch, Yachad members will sit with their advisor and peers.

Name of family, or families, you would like to sit with:

**In order to help families keep in touch, we will be compiling a contact list to send out after the Shabbaton. *

Please check here if you DO NOT wish to have your contact information shared with others.
Please check here if you WOULD like to have your contact information shared with others.

ORTHODOX UNION - MEDIA RELEASE

In consideration of the right for me to participate in Orthodox Union events and for my appearance in promotional photographs, images, videos, motion pictures, performances, brochures, websites, or related materials, I – on behalf of myself and my heirs and assigns – hereby agree as follows:

I irrevocably authorize The Union of Orthodox Jewish Congregations of America (“Orthodox Union”), and its subsidiaries, affiliates, officers, directors, agents, employees, successors and assigns (collectively and individually “OU Producers”) to photograph, film, videotape, record, reproduce, portray, and otherwise exploit my appearance, voice, name, biographical information, image, and actual or simulated likeness (collectively and individually, “Likeness”), and to use the results and proceeds thereof, including all video and audio recordings, photographs, and film or any other media (collectively and individually, “Recordings”) secured by, produced by or on behalf of the OU Producers that incorporates any of the foregoing, for any purpose whatsoever, all without further obligation or compensation. The foregoing rights extend to all media, in all forms and versions, now known and hereafter devised, throughout the universe and in perpetuity and in any ancillary exploitation thereof, including in connection with publicity and advertising. I shall have no rights of review or approval regarding the aforementioned Recordings and the OU Producers shall have the right to edit or delete those Recordings in their sole discretion. I understand that all rights in and to the recordings made about my participation, including the negatives, film, video, outtakes, sounds, and the images contained therein, shall be Orthodox Union’s sole and absolute property.
I release and forever discharge the OU Producers from all causes of action, suits, debts, damages (including injury to or death of any person or persons or injury to or damage to property), claims, judgments, costs and expenses (including attorneys’ fees) and liability of any type or kind whatsoever (collectively and individually “Claims”) arising from or in connection with: (a) my participation in events; and (b) the use or publication of any Recordings of me made in connection with my participation in events. I waive any right of privacy associated with my likeness, appearance, biographical information, and name. I waive any right to compensation related to the use of my Likeness. I hold harmless and release and forever discharge Orthodox Union from all claims which I now have or may hereafter have for invasion of privacy, defamation, or any other cause of action, in connection with my Likeness or by reason of this Media Release.
As between Orthodox Union and me, Orthodox Union shall be the exclusive owner of the Recordings and all intellectual property rights in the same, including rights under copyright. To the extent that any intellectual property rights arising from the use of my Likeness in the Recordings may not vest in Orthodox Union, I hereby transfer to Orthodox Union the entire rights, title, and interest in and to the same, throughout the universe and in perpetuity, and all grants, permissions, and consents enumerated in this Media Release.
I HAVE READ THIS AGREEMENT AND AM FULLY AWARE OF ITS CONTENTS AND THE RISKS INVOLVED IN MY PARTICIPATION, AS WELL AS THE LICENSE, AND RELEASE, I HAVE AGREED TO HEREIN. I VOLUNTARILY ACCEPT AND ASSUME THE RISKS ASSOCIATED WITH PARTICIPATION, AS WELL AS THE LICENSE, AND RELEASE I HAVE AGREED TO HEREIN.
I warrant that I am at least eighteen years of age (or, if not, that my parent or legal guardian has agreed to the foregoing and signed below) and that I have the full, complete, and unrestricted right and authority to enter into a contract for myself (or, if not, that my parent or legal guardian has agreed to the foregoing and signed below), and on behalf of my heirs and assigns.
If any provision of this agreement is held to be unenforceable, the remainder of it shall continue to be in full force and effect.

MEMBERS

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CONSENT OF PARENT OR GUARDIAN (IF APPLICABLE)

As the parent or guardian of the minor(s) named above, I hereby expressly approve and consent to this Media Release and Agreement and agree to all of the foregoing terms on behalf of myself and the minor(s), for whom I have every right to contract for in the above regard. For good and valuable consideration, I hereby guarantee that the minor(s) shall not at any time disaffirm the terms and conditions of this Media Release by reason of the minor’s minority or otherwise. The consideration provided for and referenced in the Media Release shall be deemed to be the consideration in full for all rights granted to the OU Producers and for all obligations undertaken pursuant to the Media Release and pursuant to this parental consent, not only by the minor(s) but also by me.

Date

Parent Printed Name

Telephone Number

Parent Email

Parent Address

SHABBATON PAYMENT

Applications are not considered completed until payment has been received by the Yachad office or a payment plan has been initiated. Reservations can only be guaranteed once an application is complete.

If you have a scholarship code, please enter it

If you would like to apply for a scholarship, please contact Elliot Cohen before filling out this application at CohenE@ou.org or 844-4-YACHAD (844-492-2423).

Adults (ages 10+) at $295 per person
Children 7-9 at $125 each
Children 4-6 at $75 each
Children 0-3 FREE
Additional room charge: $100/night
Roll-away mattress / Inflatable mattress: $25/night
(Choice of roll-away or inflatable made at sole discretion of the hotel)

**PLEASE NOTE:
King room = one king bed, one sofa-bed (full-size mattress) and the ability to add one roll-away / inflatable mattress; capacity 5 people. Queen room = two queen beds, one sofa-bed (full-size mattress); capacity 6 people. One crib may be added to each room. No exceptions per hotel policy! Rooms will be assigned at discretion of Yachad.

Please help us defray costs by sponsoring a program or session. You may donate here or contact Elliot Cohen at CohenE@ou.org or 844-4-YACHAD (844-492-2423). Thank you.

Application Details

Description	Quantity	Unit Price	Total
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{{ cart.seven_to_nine.name }}	{{ cart.seven_to_nine.qty }}	${{ cart.seven_to_nine.sub_total }}	${{ cart.seven_to_nine.total }}
{{ cart.four_to_six.name }}	{{ cart.four_to_six.qty }}	${{ cart.four_to_six.sub_total }}	${{ cart.four_to_six.total }}
{{ cart.zero_to_three.name }}	{{ cart.zero_to_three.qty }}	${{ cart.zero_to_three.sub_total }}	${{ cart.zero_to_three.total }}
{{ cart.additional_rooms.name }}	{{ cart.additional_rooms.qty }}	${{ cart.additional_rooms.sub_total }}	${{ cart.additional_rooms.total }}
{{ cart.inflatable_mattress.name }}	{{ cart.inflatable_mattress.qty }}	${{ cart.inflatable_mattress.sub_total }}	${{ cart.inflatable_mattress.total }}
Total:			${{ cart.total }}
Scholarship Total:			${{ cart.scholarship }}

Payment Option *

Pay by Credit Card

Pay by Check/Money Order *

I have worked out a credit card payment plan with the Yachad office **

Registration is currently closed, by submitting this application you will be placed on our waitlist. We hope to remove everyone from the waiting list and will be in touch with you regarding payment at that time

Checks can be mailed into Yachad office:
Yachad
3200 W. Touhy Ave.
2nd floor
Skokie, IL 60076

Payment Information

Name on Card *

Credit Card No *

Expiration *

CVV *

(What is this?)

This is a security code of 3-4 digits, normally found on the back of credit cards, or on the front of American Express cards.

* If you choose to pay by check, your application and reservation will NOT be processed until payment is received.
** To set-up a credit card payment plan please contact Elliot Cohen at cohene@ou.org or 844-4-YACHAD (844-492-2423).

Yachad Shabbaton 2024

PARENT/ GUARDIAN INFORMATION (ONLY THOSE ATTENDING)

Please List all Non Married Children (Including Members) Attending:

MARRIED CHILDREN OR OTHER FAMILY ATTENDING

Please list children attending with "other relative":

CHILD / ADULT WITH DISABILITY INFORMATION

Medication

ROOMING REGISTRATION

Room {{ (index + 1) }}

MEAL SEATING

LEARN ABOUT YACHAD

ORTHODOX UNION - MEDIA RELEASE

SHABBATON PAYMENT