Youth Department 2022-2023 - Form - Congregation Or Tzion

Youth Programming Registration Form
Please complete one form per participant.

Use this form if you have NOT paid the youth group fee when filling out your Gift of the Heart form.
If you have paid the youth group fee, please use this form CLICK HERE

* Participant's First Name

* Paticipant's Last Name

Paticipant's Cell Number

Paticipant's Email

* Date of Birth

* Age as of 8/2022

* Gender

* Name of Secular School

* Grade as of 8/2022

* T-Shirt Size

Or Tzion Member - Kadima (3rd - 6th Grade) - $100Non-Member - Kadima (3rd - 6th Grade) - $154Or Tzion Member - Or Tzion Teens (7th - 12th Grade) - $118Non-Member - Or Tzion Teens (7th - 12th Grade) - $172

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 Program. 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

Or Tzion Youth Code of Conduct

While attending an Or Tzion Youth Event attendees are expected to follow the code of conduct as laid out by the USCJ including but not limited to:

No smoking, no vaping, no possession of cigarettes, e-cigarettes, or anything associated.
There is to be no possession or use of any narcotics, marijuana, illegal drugs, or prescription drugs as well as no matches, firecrackers, knives, or dangerous objects
There will be no consumption of Alcoholic beverages, shoplifting, disruptive behavior, or inappropriate behavior.
Attendees must stay with the group during a specified time unless otherwise arranged with Youth Director.
There is a zero-tolerance policy regarding any activity that can be construed as bullying, hazing or harassment including cyberbullying and the use of technology to engage in harassment.

Any violation of these terms may result in immediate dismissal from the Youth Program.

This signature confirms that parent and child have reviewed and agreed to these terms

* Parent Signature

Student Signature

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