WHUSY 2016-2017 Membership Form
New this year - fill out a West Hartford USY Membership form online and pay membership via PayPal.

Parents: For health and safety reasons, we require every youth group participant to have a registration form on file. If any of this information should change throughout the year, please let us know. The $40 membership fee includes Chapter, Regional, and International dues, and will help to defray the costs of chapter programs. Thank you for your cooperation!

If you have any questions, please contact Jason Kay at 609‐651‐0891 or email whusy18@gmail.com.

Payment options ($40):
1) Pay via PayPal to whusy18@gmail.com
2) Send a check to USY, Beth El Temple, 2626 Albany Ave. West Hartford, CT 06117
3) Bring a check to a WHUSY event

Name of USYer *
Your answer
Hebrew Name
Your answer
Birthday *
MM
/
DD
/
YYYY
Address (number and street) *
Your answer
City *
Your answer
Zip code *
Your answer
USYer's Phone Number *
Your answer
USYer's E-mail Address *
Your answer
Parent 1 Name *
Your answer
Parent 1 Phone Number *
Your answer
Parent 2 Name
Your answer
Parent 2 Phone Number
Your answer
Please provide any parent email address if you wish to receive program updates (typically every 1-2 weeks) - separate multiple addresses by a comma
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
Primary Care Physician Name *
Your answer
Primary Care Physician Phone Number *
Your answer
Medical Insurance Company *
Your answer
Medical Insurance Policy ID Number *
Your answer
Allergies or Other Relevant Information *
Your answer
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