INFORMATION SHEET PAGE 2

Was your mother born Jewish? _______ If not, has she been converted? _________________

Mother’s Name ________________________Father’s Name ______________________________

Home Phone # ___________________ Home Phone # ______________________

Work Phone # ____________________ Work Phone # _______________________

Cell Phone #______________________ Cell Phone # __________________________

Best place to call: ________________________________________________

Married _____ Separated ____ Divorced ____ Widowed ____ Child lives with ____

Other siblings________________________________________________________________________

Are they involved in the Temple Beth Am Youth Groups?

How? ______________________________________________________________________________

If not, how can we get them involved: ___________________________________________________

Name of School _______________________ School Grade as of 8/1/08 _____________

Are there any disabilities or problems we should know about that may affect your child’s attendance or participation at events?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List two emergency contacts, their relationship and phone #s:

1. _______________________________________________________________________________

2. _______________________________________________________________________________

Child’s Physician ________________________________Doctor’s Phone # _____________

Health Insurance Company _____________________________ Policy # _____________________

Address: ____________________________ Phone #: _____________________________________

(Please fill in the medical and insurance information fully)

PARENTAL RELEASE and FEES CHART

I hereby give permission for my child, ____________________________, to participate in the 2008-2009 Youth Department program at Temple Beth Am, on both Regional and Sub-Regional Levels. In the event of an emergency, surgical or otherwise, and I cannot be reached, I hereby give permission for my child to be transported to the nearest medical facility and specifically authorize the representative of Temple Beth Am to select a physician and/or authorize medical treatment, including hospitalization, anesthesia, injection or other measures which he/she feels are in the best interest of my son/daughter.

Further, I give my permission to allow my son/daughter to travel by bus to chapter/ sub regional and regional events.

Parent’s Signature __________________________________________ Date ____________________

Emergency Contact Number: _________________________________________________________

**I understand that this waiver that I sign will be the predominant permission slip for the year for my child unless another slip is required**

Dues (see chart) $ ____________ (Make checks payable to Temple Beth Am)

Dues include:

Chapter T-shirt, office overhead, photocopying, postage, mail outs, flyers, office supplies, membership to the United Synagogue Youth Group (regionally and internationally)

Not included:

Programming and transportation costs throughout the year

This year we are charging an extra $10 so that every USY member can have their own copy of Siddur Sim Shalom

	USY	Kadima	Chalutzim
TBA Members	$110	$85	$80
Non-TBA Members	$165	$135	$100
Unaffiliated Members	$210	$190	$160

TSHIRT SIZE-please circle

S	M	L	Xl	XXL
YM	YL

PLEASE COPY THE FOLLOWING INFORMATION FOR YOUR RECORDS:

Temple Beth Am of Margate~7205 Royal Palm Blvd~Margate~ Florida~33063~

Phone: 954-968-1806~ Fax: 954-970-4281~www.beth-am.org~bedrocks753@hotmail.com

Ck # _________

Cash: _______

Assess to Temple ______.

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