Kadima Youth Group Registration 2019-2020
TBE's Youth Group for 5th, 6th, 7th, and 8th Grades
Please fill out an individual form for each child you wish to register.
Membership Dues are $30
Please make checks payable to: Temple Beth El.
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Email *
Child's First Name *
Child's Last Name *
Street Address *
City *
Zip Code *
Phone Number *
Gender *
Graduation Year *
Date of Birth *
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DD
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Parent Info
Parent 1 First Name *
Parent 1 Last Name *
Parent 1 Phone number *
Best email address for parent correspondence: *
Parent 2 First Name
Parent 2 Last Name
Parent 2 Phone Number
Best email address for parent correspondence: *
Student's Grade for 2019-2020 *
Please check off how you will pay this year.
Clear selection
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: *
Emergency Contact
In case of an emergency, whom shall we contact if parents are unavailable?
Name *
Relationship *
Phone Number *
Physician: *
Phone Number *
Health Insurance Provider: *
Identification Number: *
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. *
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. *
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