USY Membership 2024-25 - Form - Congregation Ohev Shalom

USY Membership Form 2024-2025
Grades 8-12 Dues for COS Members: $55
Grades 8-12 Dues for COS Non-Members: $100
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In house programs will be free of charge for all those that have paid dues for USY, unless a special guest is brought in. Paid USY members will receive discounts on special guest and out of house programs.

USYer Information

How many teens are you registering?

* USYer Name

First & Last Name

* USYer Phone Number

Cell Number or Most Used

* USYer Email

* Birthdate

Format: Day/Month/Year

Instagram User Name

* Grade as of August 2024

* Sex

* USYer Name

First & Last Name

* USYer Phone Number

Cell Number or Most Used

* USYer Email

* Birthdate

Format: Day/Month/Year

Instagram User Name

* Grade as of August 2024

* Sex

* 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

Teen 1 - Member RateTeen 2 - Member RateTeen 1 - Non-Member RateTeen 2 - Non-Member RateTeen 1 - Kol HaKavodPlease select according to your membership at Congregation Ohev Shalom as well as how many teens you are registering.

* 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 teen to participate in all USY 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 ReleaseI 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.

* USYer Consent

USYer ConsentPlease 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