REGISTRATION FORM Name(Required) First Last Email(Required) Cell phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Shul Affiliation(s)(Required) Number of years you have lived in Boca(Required)Age bracket(Required) 20-30 31-40 41-50 51-60 Who referred you to apply to this program?(Required) Are you currently employed?(Required) Yes No Other Where are you employed?(Required) What is your role?(Required) What do you hope to gain from this cohort? Please share briefly.(Required) Are there any specific topics of interest you would like to learn more about related to communal engagement, non-profits and leadership?(Required) Preferred meeting times - check all that apply(Required) Sunday mornings Sunday evenings Weekday mornings Weekday afternoons Weekday evenings Select AllList the names of Boca organizations with which you are currently involved(Required) Add RemoveList the names of organizations (also outside of Boca) with which you have previously been involved Add RemoveHave you previously served or do you currently serve in a volunteer role or leadership position?(Required) Yes No Please briefly list any past or current volunteer leadership roles and experiences and which organizations you are currently involved in.(Required) Have you had past leadership training experiences?(Required) Yes No Please briefly list those experiences and share any benefits or challenges you had with previous lay leadership training experiences.(Required) Consent(Required) I agree to the media releaseORTHODOX UNION MEDIA RELEASE From time to time, The Union of Orthodox Jewish Congregations of America, and its programs, employees and agents (together, the “Orthodox Union”) take photographs and videos of individuals, including minors, who attend or participate in Orthodox Union events, programs, and other offerings. The Orthodox Union engages in these activities for purposes relating to the advancement of the religious, spiritual, charitable, and educational goals and objectives of the Orthodox Union, including but not limited to the sharing of photos/videos in newsletters, on our blogs, and on our website and social media pages for the purpose of keeping our members and others informed of the Orthodox Union’s events and other activities. Please complete this form to give us permission to take photos/videos of you and/or your children when you participate in Orthodox Union events or programs and to use those photos/videos in our printed and online publicity: I hereby authorize the Orthodox Union to take photographs and/or video of me (or my children) when I (or my children) participate at Orthodox Union events or programs. I grant the Orthodox Union full rights to use and share the images resulting from the photographs and/or videos and any reproductions thereof (the “Recording”), in whole or in part, along with my (or my children’s) name, biographical information and quotations for any purpose including fundraising, publicity, advertising, or on social media, all without further obligation or compensation. I hereby waive any right of review or approval regarding the Recording and the Orthodox Union shall have the right to edit or delete the Recording in its sole discretion. I understand that all rights in and to the Recording shall be the Orthodox Union’s sole and absolute property. I understand that if I access the Orthodox Union’s services through a third party platform, product, service, or application (a “Third Party Service”), content and related information generated while accessing OU’s services in this manner may be monitored, captured, and or recorded by the third parties that provide such Third Party Services. I consent to the use and sharing of personal information by any such third party as described in the privacy policy available through the Third Party Service. I release and forever discharge the Orthodox Union from all causes of action, suits, or liability of any kind arising from or in connection with the use or publication of any Recording of me or my children made in connection with my participation in Orthodox Union events. I waive any right of privacy associated with the Recording and I waive any right to compensation related to the use of the Recording. I HAVE READ THIS AGREEMENT AND AM FULLY AWARE OF ITS CONTENTS, INCLUDING THE RELEASE THAT 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 and unrestricted 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). If any provision of this agreement is held to be unenforceable, the remainder of it shall continue to be in full force and effect. This waiver shall remain in effect until such time as I advise the OU otherwise in writing. Course cost Price: Staff code Total
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