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CBS Youth Membership Form
Please Select Which Youth Group
Payment can be brought into Congregation Beth Shalom via check. Please make all checks payable to CBS Youth. **********8th Grade Members of CBS will receive a FREE Kadima membership and are invited to Attend CBS USY Programs in January, 2020!
Chaverim (2nd-5th Grade) $30
Kadima (6th-8th Grade) $40
USY (9th-12th Grade): One Year $50
Lifetime USY Membership: Freshman (4 years) $150
Lifetime USY Membership: Sophomore (3 years) $115
Lifetime USY Membership: Senior Special Rate $40
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Child lives with
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Home phone number
Child/ teen's phone number
Grade in fall 2019
Synagogue affiliated with:
Religious Participation Form
Please select all that you are able to lead
G'lilah (Bind Torah)
Friday Night Kiddush
Shabbat Morning Kiddush
Hagbah (Lift Torah)
Parent/ Guardian Information
Parent 1: Name
Parent 1: Home Phone
Parent 1: Cell Phone
Parent 1: Email Address
Parent 2: Name
Parent 2: Home Phone
Parent 2: Cell Phone
Parent 2: Email Address
Emergency Contact Information
Emergency Contact Name:
Emergency Contact Relationship
Emergency Contact Phone Number:
Emergency Contact Alternate Phone Number
Emergency Contact #2 Information
Emergency Contact #2 Name:
Emergency Contact #2 Relationship
Emergency Contact #2 Phone Number:
Emergency Contact #2 Alternate Phone Number
Release, Insurance & Health Information
I hereby authorize the staff to seek medical emergency assistance for my child if required. I also hereby fully release and discharge Congregation Beth Shalom, its agents, and property owners from any and all claims from injuries, damage or loss which may occur or which may accrue to my child on account of his/her participation in events sponsored by Congregation Beth Shalom’s Youth Department. I further agree to indemnify, hold harmless and defend Congregation Beth Shalom and its agents from any and all claims resulting from injuries, damages, and losses sustained by my child and arising out of, connected with, or in any way associated with the activities of these programs or events. Initial Below:
WE WILL BE TAKING PHOTOGRAPHS AND VIDEO AT OUR EVENTS FOR USE ON THE CBS WEBSITE AND IN MARKETING MATERIALS PLEASE CHECK HERE IF YOU WOULD NOT LIKE YOUR PICTURE USED IN THIS MANNER.
I would not like my child's pictures used in this manner
Text Message Permission
WE WILL BE SENDING OUT PERIODIC TEXT MESSAGES THROUGHOUT THE YEAR WITH EVENT UPDATES. PLEASE CHECK HERE IF YOU WOULD NOT LIKE TO RECEIVE THESE MESSAGES.
I would not like to receive text message updates.
Code of Conduct
I HAVE READ THE CODE OF CONDUCT FORM (FOUND ONLINE OR IN THE YOUTH LOUNGE) AND AGREE TO ABIDE BY ITS TERMS. I understand that violation of any portion of the Code of Conduct will subject the participant to immediate disciplinary measures, including, but not limited to, being barred from participation, being sent home at parents’ expense, liability for monetary damages and suspension from future events and activities.
Were you referred by a USY Member to join? If yes, who?
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