USY Membership Form 2022-23 - Form

USYer's First Name:

USYer's Last Name:

Address:

City:

Zip Code:

Home Phone:

USYer's Email Address:

Birthday:

Parent #1 - Name:

Parent #1 - Email:

Parent #1 - Mobile:

Parent #2 - Name:

Parent #2 - Email:

Parent #2 - Mobile

* My child is fully COVID-19 vaccinated.

Yes - My child is carrying their proof of vaccination and will have it available to show upon request or I have given a copy of the card to the office to keep on file.No

Please list all allergies:

Please note that many of our events include food. If your child has an allergy:

My Child's allergies require an epi pen. He/she will self carry at all chapter functions.My Child has no allergies.

Is the USYer born of a Jewish mother or converted to Judaism?

YesNoThe Conservative Movement requires that members of USY be Jewish according to the traditional ritual definition of Jewish identity, either being born of a Jewish mother or having gone through a process of conversion or ritual affirmation of membership in the Jewish People. Should you wish, Rabbi Rosin would be happy to discuss your individual situation

Grade:

Neve Shalom Member: 9th ($54.00)Neve Shalom Member: 10th ($54.00)Neve Shalom Member: 11th ($54.00)Neve Shalom Member: 12th ($54.00)Neve Shalom Associate Member: 9-12th ($72.00)Non-Member: 9-12th ($72.00)Neve Shalom Member: 6-8th ($36.00)Associate Member: 6-8th ($54.00)Non-Member: 6-8th ($54.00)Scholarship money is always available. If dues are a financial concern, please email youthfund@neveshalom.net.

* I give permission for my child's photo to be used on social media and publicity materials:

YesNo

*If you belong to another synagogue which has a USY chapter, you may not join Neve Shalom’s chapter without permission from your synagogue. Please contact Neve Shalom’s Youth Chair at youth@neveshalom.net for more information

Do you belong to a synagogue?

YesNo

If so, which synagogue do you belong to?

* Neve Shalom USY Permission Agreement (Type Your Name to Serve as Electronic Signature in box)

I do hereby consent and agree to the participation of my child in all activities of the Neve Shalom USY Youth Program. I (the parent or legal guardian) of the applicant state that they are in good/normal health, have no physical or mental handicaps that would interfere with full participation in the program and has my permission to engage in all available activities except as noted under restrictions or modifications below. I have been made aware of the fact the events in which my child is participating may be photographed, that the photographs taken may be used both for purposes of reporting on the event or for such other use as Neve Shalom USY may determine.

In case of a medical emergency, accident or health problem where immediate treatment is deemed necessary, every effort will be made to expeditiously contact the parent(s) or guardian of the child. In the event they cannot be reached, I hereby give permission to a physician selected by the youth program, its employees, advisors or agents, to hospitalize, secure proper and ongoing treatment and to order injection, anesthesia, or surgery for my child as named above. I am aware that this form may be photocopied for use by medical caregivers.

This registration form serves as my electronic signature understanding and agreeing to the above emergency policy.

Insurance Company Name

Policy #

Emergency Contact Name

Relationship to USYer

Emergency Contact Phone #

Current Medications/Treatments

Disability, Chronic Illness, or Condition

Activity Restriction or Modification

Recent Illness, Injury, or Surgery

* We agree to abide by Neve Shalom's COVID policies

We agree to abide by Neve Shalom's COVID policies

Total amount due: