USY Membership 2018

COSUSY Membership Form 2018-2019
Grades 9-12 Dues for COS Members: Before 9/29 $85 / After 9/29 $100
Grades 9-12 Dues for COS Non-Members: Before 9/29 $385 / After 9/29 $400
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Dues Payment

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 2018

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 2018-2019 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 and Congregation Ohev Shalom.

Sat, August 17 2019
16 Av 5779

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