Please complete the form below to register your child for Youth Group at Congregation Shaarei Kodesh.

Please fill in medical and insurance information completely.

PARENTAL RELEASE**

I hereby give permission for my child to participate in the 2018-2019 Youth Department program at Congregation Shaarei Kodesh, on both Regional and Sub-Regional Levels. In the event of an emergency, surgical or otherwise, and I cannot be reached, I hereby give permission for my child to be transported to the nearest medical facility and specifically authorize the representative of Congregation Shaarei Kodesh 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 son/daughter.

Further, I give my permission to allow my son/daughter to travel by bus or car to chapter/ sub regional and regional events as well as be photographed and used in pictures to promote Youth department activities.

 **I understand that this waiver that I sign will be the predominant permission slip for the year for my child unless another slip is required**

Dues:

USY (9^th-12^th Grade)

Congregation Shaarei Kodesh members                  $135

Non-members of Congregation Shaarei Kodesh       $180

Dues include:

Chapter t-shirt, office overhead, photocopying, postage, mailings, flyers, office supplies, membership to the United Synagogue Youth Group (regionally and internationally), and programs held at Congregation Shaarei Kodesh.

Not included:

Programming and transportation costs throughout the year for programs that are not held at Congregation Shaarei Kodesh.