Youth Application Form 2021-2022

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Youth Department Membership Application 2021-2022

We are happy to inform you that Beth Shalom is now paying an annual fee to “United Synagogue Youth” in order for all of our Beth Shalom 3rd – 12th graders to become eligible for one of our three youth programs. This means that if your child wants to do any Atid/Kadima/USY programs, they no longer need to pay a membership fee every year. Simply complete the form below to enroll your child in the appropriate age program.

Select the Membership to register for

Child's First Name

Child's Middle Name

Child's Last Name

Child's Grade (as of Fall 2021)

Child's Email

Parent's Email

Address

City

Zip Code

Date of Birth

School Attending (as of Fall 2021)

Child's Cell

EMERGENCY INFORMATION

If parent(s) cannot be reached, give name of other person responsible for child who can be called

Name

Relationship

Phone

Physician to be called in emergency

Phone

Insurance Company

Policy Number

Phone

Allergies

Medications

If parents or the other person responsible for the child or the physician cannot be reached, will our Youth Department arrangements for emergency treatment be acceptable to you? We will utilize services and closest hospital emergency room

Write in your name as Signature of Parent/Guardian

Date

PARENTAL INFORMATION

Mother's Name

Father's Name

Beth Shalom Member

If No, what synagogue are you affliated with ?

Mother's Cell

Mother's Work Number

Father's Cell

Father's Work Number

Write in your name as Signature for Parent/Guardian

Date

PARENTAL CONSENT AND RELEASE

I hereby grant permission for my child to participate in youth programs of Congregation Beth Shalom, Inc. (CBS). This permission includes traveling to and from activities for any event on any type of transportation (e.g., bus, van, minivan, Uber, Lyft, automobile, taxi).
I hereby agree release and hold CBS, its officers, trustees, employees, volunteers, agents and representatives (“Released Parties”) free from any and all liability, losses or claims resulting from any damages or injuries that occur to my child, whether caused in whole or in part by an act or omission of a Released Party and, additionally, indemnify them.

In the event of an injury to the child while participating in any program, every reasonable attempt would be made to notify me. If I, for whatever reason, cannot be contacted by reasonable efforts, I grant permission and authorization (i) to those in charge to seek and administer any necessary medical attention and treatment for my child and (ii) to any hospital, doctor or medical personnel to administer whatever care and treatment they deem necessary for the best interest of my child. I expressly agree to assume full financial responsibility for all costs and related expenses arising as a result of any treatment and hold CBS and the other Released Parties harmless from any liability, loss or claim.

I understand that disruptive behavior by my child will not be tolerated and may result in my child being suspended from that event, as well as upcoming events or asked to leave the youth program. I have discussed these rules with my child and is aware of these rules.

By checking the box, I give permission for my child(ren) for the parental consent and release

By checking box, I agree to allow CBS and its employees and volunteers to publish for general circulation in any media (including social media), by Internet, etc., any photographs, video or audio recordings or artwork involving any activity in which my child has participated unless I check this box.

POLICIES AND PROCEDURES

Click here to read the policies and procedures for being a member of the Youth Department. Please print page and have both child and parent sign and date. Send to the Beth Shalom Office or you can scan and email to kusy@gmail.com.

Thu, April 18 2024 10 Nisan 5784