Kadima Membership 2019 - Form - Congregation Ohev Shalom

COS Kadima Membership Form 2019-2020
Grades 6-8 Dues for COS Members: Before 9/29 $80 / After 9/29 $95
NON COS may only attend events on COS property - $25 per event
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* Dues Payment

Dues PaymentPayment for Kadima dues - 2019/2020 Programming Year

Kadima Information

* Kadimanik Name

First & Last Name

* Kadimanik Phone Number

Cell Number or Most Used

Kadimanik Email

* Street Address

* City

* Zip Code

* Birthdate

Format: Day/Month/Year

* Grade as of August 2019

* Sex

Social Media Outreach

Social Media OutreachPlease send me Kadima updates through my social media outlets!

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 both 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 ConsentIf 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 ConsentI give permission for my child to participate in all Kadima events both at the synagogue and on trips for the 2019-2020 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).

* Kadimanik Consent

Kadimanik ConsentI understand that I will follow all the rules set by USY, Ohev Shalom Youth Committee, and Congregation Ohev Shalom Kadima.