Youth Department 2020-2021

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Youth Programming Registration Form
Please complete one form per participant.

ONLY USE THIS FORM IF YOU'VE ALREADY PAY YOUTH DEPARTMENT FEES WHEN YOU FILLED OUT YOUR GIFT OF THE HEART DONATION FORM.

Enrollment in Or Tzion’s youth groups is contingent upon the signed child and parent’s code of conduct forms. Click Here

Please contact Shayna Millman at at shayna@congregationortzion.org with questions or for assistance.

* Participant's First Name

* Paticipant's Last Name

Paticipant's Cell Number

Paticipant's Email

* Date of Birth

* Age as of 8/2020

* Gender

* Name of Secular School

* Grade as of 8/2020

* T-Shirt Size

Youth Group

Or Tzion Member: Kadima (4th-6th grades)Non-member: Kadima (4th-6th grades)Or Tzion Member: USY (7th-12th grades)Non-member: USY (7th-12th grades)

Medical Information

* Physican's Name

* Physician's Phone

* Insurance Carrier

* Policy Number

* Please list all known allergies to Medications

* Please list all prescription medications participant is currently taking.

* Please list all medical conditions of participant

Please list all food allergies. (Gluten Free/Intolerant, Dairy Free, Vegetarian, and others)

Events

I hereby authorize my child to participate in events and programs with Or Tzion's Youth Groups, USY & Kadima. I agree to hold our Congregation (including its board, officers, staff, and volunteers) harmless from any and all claims that may arise out of his/her participation in programs.
Note: Parents will receive advance notice about all programs held throughout the year.

* Events Authorization

We AuthorizeWe DO NOT Authorize

Publicity Release For Minors

We occasionally submit pictures of our activities for publication and/or post them on our website. Please select your permission to publish pictures of your child. I hereby consent to the publication of photographs, quotes, and video of my son/daughter on the Or Tzion website and social media sites for the duration of my child's enrollment. Please note if you are okay with pictures and video and name listing, or okay for pictures and videos with names withheld.

* Publicity Release for Minors

Yes With NameYes Without NameNo

* Parent Signature

* Date

Parent or Guardian Information

* Parent's or Guardian's First Name

* Parent's or Guardian's Last Name

* Parent's or Guardian's Email

Home Phone

* Cell Phone

Work Phone

* Preferred Phone

Occupation

Place of Work

Parent's or Guardian's First Name

Parent's or Guardian's Last Name

* Parent's or Guardian's Email

Home Phone

Cell Phone

Work Phone

* Preferred Phone

Occupation

Place of Work

Emergency Contacts

Please list two emergency contacts. Parents or Guardians will ALWAYS be called first.
Parent or Guardian can be one emergency contact the second must be a non-parent or guardian.

* Emergency Contact

* Relationship

* Best Number

Notes

Emergency Contact

Relationship

Best Number

Notes

Payment Information

Thu, April 25 2024 17 Nisan 5784