B'nai Aviv Youth Department Registration Form 2017-2018
Please register ONE form per child. This is a mobile friendly form.
Please note that B'nai Aviv's Youth Department is not a profit making center for the Temple. In fact, in our efforts to provide a top-notch program at a reasonable cost, the synagogue financially supports the youth budget, which runs at a deficit. We ask that you please make an additional donation. Thank you!
Name of Group *
Last Name of Participant *
Your answer
First Name of Participant *
Your answer
Participant's Cell Phone # - Format (555-555-5555)
Your answer
Participant's Email Address
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Grade as of September 1st *
Your answer
Home Phone # - Format (555-555-5555)
Your answer
School Name
Your answer
Mother's Name
Your answer
Mother's Work Phone # - Format (555-555-5555)
Your answer
Mother's Cell Phone # - Format (555-555-5555)
Your answer
Mother's E-mail Address
Your answer
Father's Name
Your answer
Father's Work Phone # - Format (555-555-5555)
Your answer
Father's Cell Phone # - Format (555-555-5555)
Your answer
Father's Email Address
Your answer
Participant's Hebrew Name
Your answer
Mother's Hebrew Name
Your answer
Father's Hebrew Name
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone # - Format (555-555-5555)
Your answer
Emergency Contact Relationship to Participant
Your answer
Child's Physician
Your answer
Physician's Phone # - Format (555-555-5555)
Your answer
Health Insurance Company
Your answer
Health Insurance Policy #
Your answer
Medications Taken Regularly
Your answer
Allergies & Restrictions
Your answer
Do you attend Religious School?
Do you attend Hebrew High School?
Do you attend Jewish Day School?
Were you Bar/Bat Mitzvah?
Other Jewish Youth Programs Attended
Your answer
Check here if you or parents DO NOT wish to receive text message reminders of upcoming youth programs.
Check here if you DO NOT wish to have your child's photos added to any OUTSIDE publication.
Check here if you DO NOT wish to have your child's photos added to any INSIDE B'nai Aviv publications.
I hereby grant permission for my child to participate in the B'nai Aviv Youth Groups for the 2017-2018 year. I also understand that this form grants permission for my child to travel with USY/Kadima/Chalutzim on either a coach bus, school bus, mini van, or personal parent's vehicle for any chapter, sub-regional, or regional event during the year. In the event that transportation in provided in any other form, I will be notified by the youth advisor. *
Required
I hereby agree to hold B'nai Aviv, its officers, directors, agents, servants, employees, and/or representatives free from any and all liability resulting from any injuries that might occur to my child. In the event of any injury, every reasonable attempt will be made to notify me. Should I not be able to be contacted by reasonable efforts, I hereby grant permission to those in charge to seek and administer any and all necessary required medical attention and treatment for my child. I further grant permission and authorization to any hospital, doctor, or medical practitioner to administer whatever medical and treatment necessary to my child. I hereby agree to assume full responsibility for all costs incurred needing any medical attention. *
Required
I further understand that USY/Kadima/Chalutzim are bound by the rules and dietary restrictions of keeping kosher. At no time is the purchase and/or consumption of any shellfish, non-kosher meat or poultry permitted. Further, I understand that disruptive behavior by my child will not be tolerated and may result in my child being suspended from upcoming events and/or activities. B'nai Aviv Youth Programs may require that a permission form be handed in to the youth office by the required deadline. We reserve the right to limit reservations on a first-come, first-served basis. In the even that a permission form is not handed into the youth office by the required deadline and your child is dropped off on the date of the activity, we are not responsible for he supervision of your child. *
Required
I know someone who may be interested in the youth programs and would like for the youth advisor to contact them. Below is their name and contact information.
Your answer
By typing your name here, you and your child understand all the rules and policies set forth. *
Your answer
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