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Youth Group Member Registration 2023-2024
Please verify reCaptcha before submitting the form.
CSK USY YOUTH GROUPS
Youth group empowers Jewish youth to develop friendships, leadership skills, a sense of belonging to the Jewish People, a deep engagement with and love for Israel, and a commitment to inspired Jewish living through meaningful and fun experiences based on the ideology of Conservative Judaism. By enrolling in Religious School, your child is automatically a part of our USY Youth Program. Youth Group dues cover all on-campus activities.
Click for more information about Chaverim (grades 3-5), Gesher (grades 6-8) and USY (grades 9-12)
Click here for more information about USY USCJ's Youth Movement
MEMBERS/CHAVERIM PLEASE LOG IN TO YOUR ACCOUNT BEFORE YOU BEGIN
GUARDIAN INFORMATION
GUARDIAN #1
*
Guardian #1 First Name
Guardian #1 Last Name
*
Local Address
City
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Guardian #1 Email
Guardian #1 Cell Phone
*
I (Guardian #1) give permission to receive messages and alerts via text to this designated cell phone.
Yes
No
Is there a second guardian?
No, there is no second guardian
Yes, I would like to add a second guardian
GUARDIAN #2
Guardian #2 First Name
Guardian #2 Last Name
Guardian #2 Cell Phone
I (Guardian #2) give permission to receive messages and alerts via text to this designated cell phone.
Yes
No
Does Guardian #2 have a different address?
No, same address
Yes, I need to enter an additional address.
Street Address
City
State
Zip
STUDENT INFORMATION
STUDENT #1
*
Student's First Name
Nickname
*
Student's Last Name
*
Student's Hebrew Name
Student's Preferred Prounouns
Student's Date of Birth
Student's Cell Phone Number (If Available)
*
I, student, give permission to receive messages and alerts via text to this designated cell phone.
Yes
No
School Attending
*
Is the student fully vaccinated?
Please Select One
Yes
No
Please email copy of most recent vaccination form to office@shaareikodesh.org
*
Has the student received the COVID Vaccine?
Please Select One
Yes
No
Prefer Not to Answer
Please share with us any other important information that will help us provide a safe and caring learning/social environment for your child.
Does your child have any ALLERGIES? (PLEASE LIST ALL ALLERGIES)
Permission to photograph/video your child and use (without names) for promotional purposes?
Yes
No
CSK USY YOUTH GROUP OPTIONS
Chaverim (Grades 3-5) at $186 (CSK Non-Member)
Chaverim (Grades 3-5) at $186 (CSK Non-Member)
Gesher (Grades 6-8) at $230 (CSK Non-Member)
Gesher (Grades 6-8) at $230 (CSK Non-Member)
USY (Grades 9-12) at $230 (Non-Member)
USY (Grades 9-12) at $230 (Non-Member)
Would you like to register a second Child?
No, I'm finished
Yes I want to register a second student
STUDENT #2
Student #2 First Name
Student #2 Nickname
Student #2 Last Name
Student #2 Hebrew Name
Student #2 Preferred Pronouns
Student #2 Date of Birth
Student's Cell Phone Number (If Available)
*
I, student, give permission to receive messages and alerts via text to this designated cell phone.
Yes
No
Grade as of 8/15/2023
Please Select One
3
4
5
6
7
8
9
10
11
12
Student #2 School Attending
*
Is the student fully vaccinated?
Please Select One
Yes
No
Please email copy of most recent vaccination form to office@shaareikodesh.org
*
Has the student received the COVID Vaccine?
Please Select One
Yes
No
Prefer Not to Answer
Please share with us any other important information that will help us provide a safe and caring learning/social environment for your child.
Does your child have any ALLERGIES? (PLEASE LIST ALL ALLERGIES)
Permission to photograph/video your child and use (without names) for promotional purposes?
Yes
No
CSK USY YOUTH GROUP OPTIONS
Would you like to register a third student?
No, I'm finished
Yes I want to register a third student
STUDENT #3
Student #3 First Name
Student #3 Nick Name
Student #3 Last Name
Student #3 Hebrew Name
Student #3 Preferred Pronouns
Student #3 Date of Birth
Student's Cell Phone Number (If Available)
*
I, student, give permission to receive messages and alerts via text to this designated cell phone.
Yes
No
Grade as of 8/15/2023
Please Select One
3
4
5
6
7
8
9
10
11
12
Student #3 School Attending
*
Is Student #3 fully vaccinated?
Please Select One
Yes
No
Please email copy of most recent vaccination form to office@shaareikodesh.org
*
Has the student received the COVID Vaccine?
Please Select One
Yes
No
Prefer Not to Answer
Please share with us any other important information that will help us provide a safe and caring learning/social environment for your child.
Does your child have any ALLERGIES? (PLEASE LIST ALL ALLERGIES)
Permission to photograph/video your child and use (without names) for promotional purposes?
Yes
No
CSK USY YOUTH GROUP OPTIONS
EMERGENCY CONTACT & PICK-UP INFORMATION
In addition to guardians, please list an emergency contact/authorized individual for pick up:
Name:
Phone Number:
Relationship:
Can Pick Up? Y/N
Tuition Total
APPLICATION FOR ENROLLMENT AND LIABILITY RELEASE
I hereby submit registration for my child, as listed above, for the Congregation Shaarei Kodesh (CSK) Religious School Program during the 2021-2022 school year. I understand that session and class placement of my child is left to the discretion of the Director. In the event of an emergency, I give permission for my child to be brought to the nearest medical facility and authorize the representative of Congregation Shaarei Kodesh to select a physician, nurse, paramedic or emergency medical technician licensed by the State of Florida, and/or authorize medical treatment, including hospitalization, anesthesia, injection, surgery or other measures which he/she feels are in the best interest of my child. This form also serves as a release form for any trip on which my child participates during the school year. I also, hereby release and agree to defend, indemnify and hold Congregation Shaarei Kodesh (and its officers, directors, agents, volunteers and employees) harmless from any and all damages, injuries, claims and causes of action arising (directly or indirectly) out of my or my child’s participation on any school-sponsored activity or trip. My child has my permission to participate in all activities of the Education Program for which he/she is registered.
By signing this application, the undersigned agrees to pay the total amount of tuition and fees for the 2021-2022 school year.
Refunds due to withdrawal are not available.
In the event of payment default, CSK reserves the right to cancel the student’s enrollment in school and/or youth groups and the undersigned agrees to pay the expenses of enforcement and collection, including attorney’s fees and costs.
*
I have read and understand the above paragraph and I am submitting my registration.
I have read and understand the above paragraph and I am submitting my registration.
Sun, October 1 2023 16 Tishrei 5784
