Halutzim Youth Group Registration 2018-2019
TBE's Youth Group for 3rd and 4th Grade
Please fill out an individual form for each child you wish to register.
Membership Dues are $18 (includes 3 events during the year, otherwise $8 each)
Please make checks payable to: TBE Youth Groups
Email address *
Please check off how you will pay this year. *
About Your Child
Child's Name *
Your answer
Child's Hebrew Name *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
School *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Grade *
Parent Info
Parent 1 Name *
Your answer
Parent 1 Phone number *
Your answer
Parent 2 Name
Your answer
Parent 2 Phone Number
Your answer
Best email address for parent correspondence: *
Your answer
Child's interests and activities: *
Your answer
If you feel there is anything we should know regarding your child (medications, conditions, allergies, dietary preferences, etc.) in case of an emergency please leave that information below: *
Your answer
Emergency Contact
In case of an emergency, whom shall we contact if parents are unavailable?
Name *
Your answer
Relationship *
Your answer
Phone Number *
Your answer
Physician: *
Your answer
Phone Number *
Your answer
Health Insurance Provider: *
Your answer
Identification Number: *
Your answer
Liability Consent
I certify that the above information is correct and that my child is in proper physical condition to attend youth group programs. I hereby give permission for my child to participate in all trips and activities arranged by Temple Beth El and/or the Tzafon regional office. I hereby release TBE from any liability in case of accident or occurrence en route to or from and/or throughout an event. t. In case of emergency, I hereby give permission to the physician selected by the regional advisor or chapter advisor to hospitalize, secure proper treatment for, and/or order injection, anesthesia or surgery for my child, as named above, if I cannot be reached and such care is deemed medically necessary by the physician.
By selecting "Yes" I consent to the above statement. *
Typing my name below stands as my legal signature for the above statement. *
Your answer
Photo Release Consent
I hereby grant permission for films, video, and/or audio tape recordings, slides and photographs (collectively “Media”) to be taken of my son/daughter by Temple Beth El personnel during programs and volunteer activities for purposes of promoting Temple Beth El and/or its program. I authorize Temple Beth El to use my son/daughter’s image on its website and/or in other official synagogue and/or publications without further consideration, and I acknowledge Temple Beth El’s right to crop or otherwise treat the Media at its discretion.
I also understand that once my child’s image is posted to the Temple Beth El website or other related websites, the image can be downloaded by any computer user. Therefore, I agree to indemnify and hold Temple Beth El and harmless from any claims related to the permitted uses under this Photo Release.
By selecting "Yes" I consent to the above Photo Release statement. *
Typing my name below stands as my legal signature for the above statement. *
Your answer
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