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CBS Youth Membership Form
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Please Select Which Youth Group
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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, 2021!
Chaverim (2nd-5th Grade) $30
Kadima (6th-7th Grade) $40
USY (8th-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
Name
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Your answer
Gender Identity
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Female
Male
non-binary
Other:
What are your preferred pronouns?
Your answer
Birthday
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MM
/
DD
/
YYYY
Address
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Your answer
City/State/Zip
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Your answer
Child lives with
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Mother
Father
Both
Other (Specify)
Child/Teen Email
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We advertise our programs via email. Please be sure to allow email from
egolberg@bethshalomnb.org
Your answer
Home phone number
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Your answer
Child/ teen's phone number
Your answer
School District
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27
28
30
31
34
Shechter
GBN
GBS
RZJHS
Other:
Grade in fall 2020
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Your answer
T-shirt size
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XS
S
M
L
XL
XXL
Synagogue affiliated with:
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CBS
Other:
Religious Participation Form
Kohen
Levi
Israel
Clear selection
Please select all that you are able to lead
Hamotzi
English Reading
G'lilah (Bind Torah)
Aliyah
Weekday Mincha
Friday Night Kiddush
Shabbat Ma'ariv
Shabbat Musaf
Read Torah
Shabbat Morning Kiddush
Havdalah
Birkat Hamazon
Hagbah (Lift Torah)
Gabbai
Weekday Shacharit
Weekday Ma'ariv
Kabbalat Shabbat
Shabbat Sacharit
Torah Service
Chant Haftorah
Shabbat Mincha
Candle Lighting
Parent/ Guardian Information
Parent 1: Name
*
Your answer
Parent 1: Home Phone
Your answer
Parent 1: Cell Phone
Your answer
Parent 1: Email Address
Your answer
Parent 2: Name
Your answer
Parent 2: Home Phone
Your answer
Parent 2: Cell Phone
Your answer
Parent 2: Email Address
Your answer
Emergency Contact Information
Emergency Contact Name:
*
Your answer
Emergency Contact Relationship
*
Your answer
Emergency Contact Phone Number:
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Your answer
Emergency Contact Alternate Phone Number
*
Your answer
Emergency Contact #2 Information
Emergency Contact #2 Name:
Your answer
Emergency Contact #2 Relationship
Your answer
Emergency Contact #2 Phone Number:
Your answer
Emergency Contact #2 Alternate Phone Number
Your answer
Release Forms
Release, Insurance & Health Information
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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:
Your answer
Photography Release
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.
Clear selection
Code of Conduct
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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.
Student Signature
Date
Were you referred by a USY Member to join? If yes, who?
Your answer
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