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Youth Group Registration

TBE Youth Group Registration
Youth #1 Information
Youth #2 Information
Youth #3 Information
Parent Information
If no parent 2 please put N/A in the box.
If no parent 2 please put N/A in the box.
If no parent 2 please put N/A in the box.
If address differs from parent 1 please put information in the box. If address is same please put N/A.
Emergency Contacts
Parents are always contacted first, however, in case of illness, accident or injury please list additional people below who can be contacted.
Please Include:
Full name
Relationship to your child(ren)
Phone #
Include the following information:
Name of Insured
Name of Insurance Company
Policy #
Include the following information:
Doctor Name & Phone Number
Parent Consent & Release
I give my child(ren) permission to take part in the Temple Beth Emet Youth program for the current programming year. As the parent/legal guardian, I hereby release Temple Beth Emet and its staff of any and all liabilities incident to and arising out of all Temple Beth Emet Youth Programs. In addition, I hereby give permission to the group advisor to secure proper medical treatment in case of an emergency for my child(ren) as named above in the event I cannot be reached.
Both parents need to sign (even if parents are separated or divorced). If there is no parent 2 please put N/A. 
Payment Agreement
Chalutzim (Kindergarten - 4th grade): $136 Member, $250 Non-Member
Gesher (5th - 7th grade): $175 Member, $360 Non-Member
Bogrim (8th - 12th grade): $175 Member, $360 Non-Member
Credit Card & Debit Card Payment Information
(Credit card payments will incur a 3% convenience fee, there are no additional fees for debit card payments)
Mon, December 11 2023 28 Kislev 5784