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USY Gesher Membership 2021
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USY Gesher Membership Form 2021-2022
Grades 6-8 Dues for COS Members: $50
Grades 6-8 Dues for COS Non-Members: $100
__________________________________________________________________
*
Dues Payment
Please Select One
Member Rate
Non-Member Rate
Please choose either the member or non-member rate
USY Gesher Information
*
Gesher Participant Name
First & Last Name
*
Gesher Participant Phone Number
Cell Number or Most Used
*
Gesher Participant email
*
Street Address
*
City
*
Zip Code
*
Birthdate
Format: Day/Month/Year
*
Grade as of August 2021
*
Sex
Please Select One
Male
Female
Prefer not to answer
*
Gesher Participant Tshirt Size
Please Select One
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Instagram User Name
Snapchat User Name
Parent / Guardian Information
*
Parent 1 / Guardian 1 First Name
*
Parent 1 / Guardian 1 Last Name
*
Parent 1 / Guardian 1 Phone
*
Parent 1 / Guardian 1 Email
Parent 2 / Guardian 2 First Name
Parent 2 / Guardian 2 Last Name
Parent 2 / Guardian 2 Phone
Parent 2 / Guardian 2 Email
Emergency Information
In case of emergency, if parents / guardians cannot be reached, please provide another contact name.
*
Emergency Contact Name 1
*
Emergency Contact Phone 1
*
Emergency Contact Name 2
*
Emergency Contact Phone 2
*
Physician Name
to be contacted in case of an emergency
*
Physician Phone
*
Health Insurance Company
*
Policy Number
*
Emergency Consent
Emergency Consent
If parents, guardians, emergency contacts, or physician cannot be contacted, I give consent for COS youth staff to utilize services and closest hospital emergency room.
*
Release and Consent
Release and Consent
I give permission for my child to participate in all Kadima events both at the synagogue and on trips for the 2021-2022 program year and release Congregation Ohev Shalom and its representatives from any liability. I acknowledge that my child must follow all the rules set forth by the Congregation Ohev Shalom Youth Commission in coordination with the guidelines specified by United Synagogue Youth (USY) and United Synagogue Conservative Judaism (USCJ).
*
Gesher Participant Consent
Gesher Participant Consent
I understand that I will follow all the rules set by USY Gesher, the Ohev Shalom Youth Committee, and Congregation Ohev Shalom.
Thu, April 18 2024 10 Nisan 5784