Youth Group Registration Form

Guardian Information
Guardian 1 - Marital Status*
Guardian 1 - Name*
First Last
Guardian 1 - Work Phone*
Guardian 1 - Home Phone*
Guardian 1 - Cell Phone
Guardian 1 - Email*
Guardian 1 - Occupation*
Guardian 1 - Is your address the same as above?
- Yes
- No
Guardian 1 - Address
Street Address Address Line 2 City State ZIP Code
Guardian 2 - Marital Status
Guardian 2 - Name
First Last
Guardian 2 - Work Phone
Guardian 2 - Home Phone
Guardian 2 - Cell Phone
Guardian 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 State ZIP Code

Medical Information
Understanding 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 Release
I 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*
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.*
- 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.*
- Yes
- No
I 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 Contact
Other than Parents
Name*
First Last
Phone*
Relationship*
Child's Physician (Name & Phone)*
Insurance Carrier and Policy Number*
DIGITAL SIGNATURE*
First Last

Total
$0.00
Billing Address*
Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Youth Group Registration Form

2018-2019 Youth Group Registration

Step 1 of 5

Youth Information

Guardian Information

Medical Information

Guardian Release

Emergency Contact