Youth Group Member Registration 2024-2025 - 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
THIS FORM IS FOR YOUTH GROUP REGISTRATION ONLY.
IF YOUR CHILD IS A STUDENT IN THE RELIGIOUS SCHOOL,
YOU DO NOT NEED TO FILL OUT THIS FORM.

GUARDIAN INFORMATION

GUARDIAN #1

* Guardian #1 First Name

Guardian #1 Last Name

* Local Address

City

State

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.

YesNo

Is there a second guardian?

No, there is no second guardianYes, 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.

YesNo

Does Guardian #2 have a different address?

No, same addressYes, 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.

YesNo

* Grade as of Fall 2024

School Attending

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?

Please Select OneYesNo

CSK USY YOUTH GROUP OPTIONS

Chaverim (Grades 3-5) at $186 (CSK Non-Member)

Gesher (Grades 6-8) at $230 (CSK Non-Member)

USY (Grades 9-12) at $230 (CSK Non-Member)

Would you like to register a second Child?

No, I'm finishedYes 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.

YesNo

Grade as of Fall 2024

Student #2 School Attending

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?

Please Select OneYesNo

CSK USY YOUTH GROUP OPTIONS

Chaverim (Grades 3-5) at $186 (CSK Non-Member)

Gesher (Grades 6-8) at $230 (CSK Non-Member)

USY (Grades 9-12) at $230 (CSK Non-Member)

Would you like to register a third student?

No, I'm finishedYes 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.

YesNo

Student #3 School Attending

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?

YesNo

CSK USY YOUTH GROUP OPTIONS

Chaverim (Grades 3-5) at $186 (CSK Non-Member)

Gesher (Grades 6-8) at $230 (CSK Non-Member)

USY (Grades 9-12) at $230 (CSK Non-Member)

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

APPLICATION FOR ENROLLMENT AND LIABILITY RELEASE

I hereby submit registration for my child, as listed above, for the Congregation Shaarei Kodesh (CSK) Youth Group Program during the 2024-2025 school year. 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 synagogue-sponsored activity or trip. My child has my permission to participate in all activities of the Youth Program for which he/she is registered.

By signing this application, the undersigned agrees to pay the total amount of dues and fees for the 2024-2025 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 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.

Tuition Total