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USY Chaverim Membership 2024-25
Please verify reCaptcha before submitting the form.
USY Chaverim Membership Form 2024-2025
Grades 3-5 Dues for COS Members: $50
Grades 3-5 Dues for COS Non-Members: $100
__________________________________________________________________
In house programs will be free of charge for all those that have paid dues for USY Chaverim, unless a special guest is brought in. Paid USY Chaverim members will receive discounts on special guest and out of house programs. Non-COS members eligible for in-house events only.
USY Chaverim Information
How many children are you registering?
Please Select One
One
Two
*
Chaverim Participant Name
First & Last Name
*
Chaverim Participant Phone Number
If child has a cell phone
*
Birthdate
Format: Day/Month/Year
*
Grade as of August 2024
*
Sex
Please Select One
Male
Female
Non-Binary
Prefer not to answer
*
Chaverim Participant Tshirt Size
Please Select One
Youth S
Youth M
Youth L
Youth XL
Adult Small
Adult Medium
Adult Large
*
Chaverim Participant Name
First & Last Name
*
Chaverim Participant Phone Number
If child has a cell phone
*
Birthdate
Format: Day/Month/Year
*
Grade as of August 2024
*
Sex
Please Select One
Male
Female
Non-Binary
Prefer not to answer
*
Chaverim Participant Tshirt Size
Please Select One
Youth S
Youth M
Youth L
Youth XL
Adult Small
Adult Medium
Adult Large
*
Street Address
*
City
*
Zip Code
Parent / Guardian Information
*
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Phone
*
Parent/Guardian Email
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Phone
Parent/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
*
Payment Section
Child 1 - Member Rate
Child 2 - Member Rate
Child 1 - Non-Member Rate
Child 2 - Non-Member Rate
Child 1 - Kol HaKavod
Please select according to your membership at Congregation Ohev Shalom as well as how many children you are registering.
*
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 USY Chaverim events both at the synagogue and on trips for the 2024-2025 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).
*
Photo Release
Photo Release
I understand you love to share what is happening at youth group events with pictures and I consent to have my child(ren)'s picture used for any publicity.
*
Chaverim Participant Consent
Chaverim Participant Consent
Please checking this box you acknowledge that you, parent and participating youth, have read our Ohev Shalom Youth Behavior Policy and understand and agree to the specifications outlined.
Youth Behavior Policy - Form - Congregation Ohev Shalom
Fri, October 25 2024 23 Tishrei 5785