Youth Membership

Child's Name*

First Last

Age Group*

*

Male
Female

Date of Birth*

MM

DD

YYYY

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child's Email

Home Phone*

Child's Cell Phone

Name of School*

Grade for 2019-2020 School Year*

Parent/Guardian 1

First Last

Parent/Guardian 1 Address*

Same address as Child

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian 1 Phone*

Parent/Guardian 1 Secondary Phone

Parent/Guardian 1 Email*

Parent/Guardian 2

First Last

Parent/Guardian 2 Address

Same as Parent/Guardian 1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian 2 Phone

Parent/Guardian 2 Secondary Phone

Parent/Guardian 2 Email

Best Number To Call

Marital Status*

Child Lives With

Anything we should know that may limit your child's participation in events?

Please include food allergies, medical conditions, schedule conflicts, etc.

Add a Child

Click to add a child

Child's Name*

First Last

Age Group*

*

Male
Female

Date of Birth*

MM

DD

YYYY

Address*

Same as previous child

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child's Email

Home Phone*

Child's Cell Phone

Name of School*

Grade for 2016-2017 School Year*

Child Lives With

Anything we should know that may limit your child's participation in events?

Please include food allergies, medical conditions, schedule conflicts, etc.

Add Another Child

Click to add another child

Child's Name*

First Last

Age Group*

*

Male
Female

Date of Birth*

MM

DD

YYYY

Address*

Same as previous child

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child's Email

Home Phone*

Child's Cell Phone

Name of School*

Grade for 2016-2017 School Year*

Child Lives With

Anything we should know that may limit your child's participation in events?

Please include food allergies, medical conditions, schedule conflicts, etc.

Add Yet Another Child

Click to add yet another child!

Child's Name*

First Last

Age Group*

*

Male
Female

Date of Birth*

MM

DD

YYYY

Address*

Same as previous child

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child's Email

Home Phone*

Child's Cell Phone

Name of School*

Grade for 2016-2017 School Year*

Child Lives With

Anything we should know that may limit your child's participation in events?

Please include food allergies, medical conditions, schedule conflicts, etc.

Emergency Information

Emergency Contact 1*

First Last

Phone Number*

Relationship*

Emergency Contact 2*

First Last

Phone Number*

Relationship*

Physician's Name*

Physician's Phone Number*

Health Insurance Company*

Policy #*

Health Insurance Phone Number*

Parental Release

*

I hereby give permission for my child(ren) to participate in the 2019-2020 Youth Department program at Temple Israel, on both Regional and Sub-Regional levels for Kadima and USY. In the event of an emergency, surgical or otherwise, and I cannot be reached, I hereby give permission for my child(ren) to be transported to the nearest medical facility and specifically authorize the representative of Temple Israel to select a physician and/or authorize medical treatment, including hospitalization, anesthesia, injection or other measures which he/she feels are in the best interest of my child(ren). Further, I give my permission to allow my child(ren) to travel by bus to chapter/sub-regional and regional events.

Agree
Disagree

Payment

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Total Youth Group Membership Dues

$0.00

If you are in need of scholarship assistance, please contact Rabbi Neely at rabbi@tiflorida.org before submitting this form.