2020-2021 Youth Group RegistrationStep 1 of 5 20%Registration TypeChaverim (3, 4 & 5) - Temple Member - $36.00Chaverim (3, 4 & 5) - Non-Member - $200.00Jr. BOATY (6 & 7) - Temple Member - $36.00Jr. BOATY (6 & 7) - Non-Member - $250.00Jr. BOATY (8) - Temple Member - $154.00Jr. BOATY (8) - Non-Member - $250.00BOATY (9-12) - Temple Member - $180.00BOATY (9-12) - Non-Member - $280.00Youth InformationName*FirstLastDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderMaleFemaleMailing Address*Street AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeHome Phone*Youth Cell PhoneYouth EmailT-Shirt SizeChild - SChild - MChild - LAdult - SAdult - MAdult - LAdult - XLGrade as of Sept 2020*Name of secular school*Temple Member*YesNoIf you are involved with Jewish Youth / Jewish Camp - Which ones?Guardian InformationGuardian 1 - Marital Status*MarriedSingleDivorcedSeparatedWidowedGuardian 1 - Name*FirstLastGuardian 1 - Work Phone*Guardian 1 - Home Phone*Guardian 1 - Cell PhoneGuardian 1 - Email*Guardian 1 - Occupation*Guardian 1 - Is your address the same as above?YesNoGuardian 1 - AddressStreet AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeGuardian 2 - Marital StatusMarriedSingleDivorcedSeparatedWidowedGuardian 2 - NameFirstLastGuardian 2 - Work PhoneGuardian 2 - Home PhoneGuardian 2 - Cell PhoneGuardian 2 - EmailGuardian 2 - OccupationGuardian 2 - Is your address the same as above?YesNoGuardian 2 - AddressStreet AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeMedical InformationUnderstanding your child’s medical, physical, or psychological needs will help our staff secure your child’s safety, well- being, and productivity. Please indicate the applicable conditions below and elaborate as needed.Please list current medication with dosage your child is taking:Medications & Dosage*If none put N/A. Please be sure to consider ADD, Asthma, Perceptual Problems, Epilepsy, Visual Problems, Emotional Disturbances, ADHD, Learning Disabled, Diabetes, Hearing Loss, Speech Problems, Allergies or other issues.Is there any other information that you would like to share with us to help us provide your child with the most rewarding experience?Guardian ReleaseI hereby give permission for my child, (NAMED BELOW), to participate in the 2018-2019 Youth Department program at Temple Beth Orr, on both Regional and Sub-Regional Levels. As the parent/guardian of above minor child I do by hereby release, forever discharge and hold harmless Temple Beth Orr and the advisors, chaperones, and volunteers from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses. This release covers meetings on Temple Beth Orr property or any other site during programs and activities.Child's Name*FirstLastI give my permission to allow my child to travel by bus to chapter/sub regional and regional events. This release covers transportation and/or drivers provided by Temple Beth Orr and its representatives who are properly licensed to drive in the state of Florida.*YesNoI give permission for my child’s photograph/video to be taken during youth group activities and have the photograph/video used for display within the synagogue, on our website, in press releases or advertisements. The Youth Department requests respectfully your permission to photograph your child/children and will make every effort to honor your wishes when such occasions arise.*YesNoI understand that this wavier will be the predominant permission slip for the year for my child unless another slip is required.*Yes I understand**In the event of an emergency, surgical or otherwise, if 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 Temple Beth Orr to select a physician 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.Emergency ContactOther than ParentsName*FirstLastPhone*Relationship*Child's Physician (Name & Phone)*Insurance Carrier and Policy Number*DIGITAL SIGNATURE*FirstLastTotal$0.00Billing Address*Street AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeCredit Card*American ExpressDiscoverMasterCardVisaCard NumberMonth010203040506070809101112Year20212022202320242025202620272028202920302031203220332034203520362037203820392040Expiration Date Security CodeCardholder Name South Florida Web AdvisorsYouth Group Registration Form03.11.2018