*** TEMPLE BETH AM   ***

Youth Group Application 2009-2010

(Please turn the page over and continue filling in information)

WELCOME TO BEDROCK TERRITORY

Please Print Clearly

Check One:   _________Chalutzim (Grades 3-5))   _____ Kadima (Grades 6-8)

____ USY (Grades 9-12)

Full Name ___________________________ Nickname _____________   Male ____   Female ____

Full Address _____________________________ City __________________________   Zip ________

              Date of Birth _____________________   Child’s Cell Phone # ______________________

              Home Phone # ___________________   Child’s E-mail ________________________

Please fill in if Parents would like to receive email: ______________________________________

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 8/1/09 _____________

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 2009-2010 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

TSHIRT SIZE-please circle

PLEASE COPY THE FOLLOWING INFORMATION FOR YOUR RECORDS:

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

Phone: 954-968-4545 ext. 39~ Fax: 954-970-4281~

www.freewebs.com/margateusy~bedrocks753@hotmail.com~margatebedrocks@gmail.com

Ck # _________

Cash: _______