USY Membership 2021 - Form - Congregation Ohev Shalom

COSUSY Membership Form 2021-2022
Grades 8-12 Dues for COS Members: $50
Grades 8-12 Dues for COS Non-Members: $100
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* Dues Payment

Please choose either the member or non-member rate

USYer Information

* USYer Name

First & Last Name

* USYer Phone Number

Cell Number or Most Used

* USYer email

* Street Address

* City

* Zip Code

* Birthdate

Format: Day/Month/Year

* Grade as of August 2021

* Sex

Social Media Outreach

Social Media OutreachPlease send me USY 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 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 USY events both at the synagogue and on trips for the 2020-2021 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).

* USYer Consent

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