2021-2022 Youth Group Registration Step 1 of 5 20% Registration Type Chaverim (3, 4 & 5) - Temple Member - $36.00 Chaverim (3, 4 & 5) - Non-Member - $200.00 Jr. BOATY (6 & 7) - Temple Member - $72.00 Jr. BOATY (6 & 7) - Non-Member - $250.00 Jr. BOATY (8) - Temple Member - $180.00 Jr. BOATY (8) - Non-Member - $250.00 BOATY (9-12) - Temple Member - $218.00 BOATY (9-12) - Non-Member - $280.00 Youth InformationName(Required) First Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Youth Cell PhoneYouth Email T-Shirt SizeChild - SChild - MChild - LAdult - SAdult - MAdult - LAdult - XLGrade as of Sept 2021(Required) Name of secular school(Required) Temple Member(Required)YesNoIf you are involved with Jewish Youth / Jewish Camp - Which ones? Guardian InformationGuardian 1 - Marital Status(Required)MarriedSingleDivorcedSeparatedWidowedGuardian 1 - Name(Required) First Last Guardian 1 - Work Phone(Required)Guardian 1 - Home Phone(Required)Guardian 1 - Cell PhoneGuardian 1 - Email(Required) Guardian 1 - Occupation(Required) Guardian 1 - Is your address the same as above? Yes No Guardian 1 - Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian 2 - Marital StatusMarriedSingleDivorcedSeparatedWidowedGuardian 2 - Name First Last Guardian 2 - Work PhoneGuardian 2 - Home PhoneGuardian 2 - Cell PhoneGuardian 2 - Email Guardian 2 - Occupation Guardian 2 - Is your address the same as above? Yes No Guardian 2 - Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical 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(Required)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(Required) First Last I 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.(Required) Yes No I give permission for the Youth Advisor/chaperone to reach out to my child regarding upcoming events via phone and texting capabilities as well as speaking to them through mobile options while at an off campus event (Regional Events, Trips, etc.)(Required) Yes No I 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.(Required) Yes No I understand that this wavier will be the predominant permission slip for the year for my child unless another slip is required.(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(Required) First Last Phone(Required)Relationship(Required) Child's Physician (Name & Phone)(Required)Insurance Carrier and Policy Number(Required)DIGITAL SIGNATURE(Required) First Last Total Billing Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name South Florida Web AdvisorsYouth Group Registration Form03.11.2018