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Youth Application Form 2022-2023

Youth Department Membership Application 2022-2023

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 Chaverim / Gesher /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. 


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



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.


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

Sun, April 14 2024 6 Nisan 5784