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Kol Nidre Campaign
High Holidays
Youth Department Registration 2023-2024
Please verify reCaptcha before submitting the form.
The deadline to receive $15 off has been extended till September 25
*
Are you currently a member of Congregation Etz Chaim?
Please Select One
Yes
No
*
Select the appropriate youth group for your child's grade level
Please Select One
Chalutzim (Grades K, 1 and 2)
Chaverim ( Grades 3, 4 and 5)
Gesher (Grades 6, 7 and 8)
USY (Grades 9, 10, 11 and 12)
8th Grade AND became a Bar/Bat Mitzvah at Etz Chaim
Click on the dropdown arrow to see more options
*
Select the appropriate youth group for your child's grade level
Please Select One
Chalutzim (Grades K, 1 and 2)
Chaverim ( Grades 3, 4 and 5)
Gesher (Grades 6, 7 and 8)
USY (Grades 9, 10, 11 and 12)
Click on the dropdown arrow to see more options
Child's Information
*
Child's First Name
*
Child's Last Name
*
Hebrew Name
*
Date of Birth
*
Gender
Grade (as of September 2023)
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
*
Cell Phone
*
Email
*
School Attending
*
T-Shirt Type
Please Select One
Child
Adult
*
Select T-Shirt Size
Please Select One
S
M
L
XL
XXL
Parent's Information
*
Parent's/Guardian's First Name
*
Parent's/Guardian's Last Name
*
Child Lives with Me
Please Select One
Yes
No
*
Jewish?
Please Select One
Yes
No
*
Cell Phone
*
Email
*
Address
*
City
*
Zip
*
Additional Parent/Guardian?
Please Select One
Yes
No
*
Additional Parent's/Guardian's First Name
*
Additional Parent's/Guardian's Last Name
*
Child Lives with Me
Please Select One
Yes
No
*
Cell Phone
*
Email
*
Address
*
City
*
Zip
Emergency, Safety and Security Information
*
Primary Care Physician
*
Phone Number
Allergies
Medications
*
Insurance Company
*
Policy Number
*
Group Number
*
Member Number
*
Phone Number
*
Address
*We understand that we have participants whose success may depend on their unique needs being addressed. For the success, and overall health & safety, of your child, please list
all
psychological and/or medical information we should know about them here, including medications (name/dosage/frequency):
*Your child(ren)’s privacy is very important to us. Great care will be taken to maintain the confidentiality of this information.
The Youth Director will share this information with your child(ren)’s youth group advisor(s), the Synagogue Executive Director, and appropriate medical personnel only as necessary.
I give permission for my child(ren) to take over-the-counter medications under supervision from the Youth Director or his/her designee
acetaminophen
ibuprofen
antihistamine
decongestant
If parents
cannot
be reached, please give the name and
phone number of two people responsible for your child(ren):
*
Name
*
Primary Phone Number
*
Name
*
Primary Phone Number
Miscellaneous Information
Please list any additional information we should be aware of, including other extracurricular activities
CONGREGATION ETZ CHAIM YOUTH DEPARTMENT
CONSENT, AUTHORIZATION, AND RELEASE
*
Child's Name
I hereby grant permission for my child, listed above, to participate in Congregation Etz Chaim Youth Programs for the 2023-2024 year. I understand that this permission form grants permission for my child to travel to activities on any mode of transportation selected, including, but not limited to a coach bus, school bus, minivan, van, personal vehicle, taxi or any other form of transportation for any event, including chapter events, sub-regional events or regional events during the 2023-2024 year.
I hereby agree to hold Congregation Etz Chaim, it’s Officers, Directors, agents, servants, employees and representatives free from any and all liability resulting from any injuries which might occur to my child named above. In the event of an injury to the child while participating in the program, every reasonable attempt would be made to notify me. Should I, for whatever reason, not be able to be contacted by reasonable efforts, I grant permission to those in charge to seek and administer any and all necessary and/or required medical attention and/or treatment for my child and I further grant permission and authorization to any hospital, doctor or medical personnel to administer whatever care and treatment they deem necessary for the best interest of my child, and I expressly agree to assume full financial responsibility for all costs and related expenses arising as a result and to hold Congregation Etz Chaim and all of its organizations and employees harmless from any such liability and agree to indemnify them.
I understand that disruptive behavior by my child will not be tolerated and may result in my child being suspended from upcoming events and/or activities or asked to leave the program. I have discussed these rules with my child and he/she is aware of the same.
*
Photo Release
Please Select One
I agree
I do not agree
to allow Congregation Etz Chaim and/or its related Departments, to publish for general circulation in any media, Internet, etc., any photographs, video clips, artwork, audio clips, involving any activity in which my child has participated.
All checks will be made out to Congregation Etz Chaim unless otherwise stated on a flyer or application.
The Youth Department prefers checks rather than cash. Due to the amount of pre-planning involved, there will be no refunds made for cancellations after deadline date. Please adhere to deadlines. All monies can be turned into the Youth Director via the office at Etz Chaim or at any youth program. No money will be accepted without proper paperwork. If payments are mailed, please address the envelope to the Congregation Etz Chaim Youth Director and make sure to allow enough time for it to arrive.
*
Parent's Signature
Type your name here as your signature
*
Date
CONGREGATION ETZ CHAIM YOUTH DEPARTMENT
CODE OF CONDUCT
Arrival/Dismissal
All participants are expected to arrive before the start of each program, and be picked up after each program concludes. If any parent must pick up their child early, they should reach out to the Youth Director and/or Advisor(s) in a timely fashion. If any child is being picked up by an adult other than their own parent or sibling, the Youth Director must receive written notice, whether through email or a signed letter provided at dropoff. USYers of driving age are
not
allowed to drive during any program.
Behavior
All Youth Department participants are to treat each other with respect and dignity. At no time will any derogatory remarks toward one another be tolerated.
Hukei Habayit
(House Rules)
With the understanding that we have different participants who are setup for success in different ways, we ask that no pets are brought into the Bayit, unless a specific activity/program asks for them. All food brought into the Etz Chaim Bayit must be marked kosher or approved by the Youth Director or Rabbi. Participants will not be allowed to leave their program unless the Advisor(s)/Youth Director deem the Bayit cleaned. In the spirit of fostering independence, we ask that Parents, unless in an official volunteer capacity, do not join us during programs.
Dress Codes
The dress code will vary from program to program. It is mandatory, however, that all those who identify as male, while in the Synagogue, wear kippot. While in the Sanctuary, everyone must have their shoulders covered. Shorts, skirts and skorts must be an appropriate length. Shirts cannot show midriff, back or cleavage and must be free of inappropriate language or insignia. Tank top straps must be two fingers in width.
Financials & Financial Assistance
While most programs that happen at Etz Chaim or the Bayit will be covered by your dues, some specialty programs (like Chocolate Seder) may incur an additional fee. All monies must be paid at the program, or in advance. Late payments may incur an additional fee. Checks are preferred, and should be made out to
Congregation Etz Chaim
with the activity and participants name on the memo line. We believe that financial need should never stop a child from participating in any of our programs. Please reach out to our Youth Director at YouthDirector@EtzChaim.net, for more information or if you have any questions.
Please be aware that, by signing below, you are indicating that you are aware of the aforementioned policies of the Congregation Etz Chaim Youth Department. If there is a violation of any said policies, our staff has been trained in regards to our standard operating procedure.
All rules and regulations set forth by the HaNegev Region, or
International USY, will be enforced by this department when applicable.
*
Parent's Signature
Type your name here as your signature
*
Child's Signature
All youth should type their name here as their signature
*
Date
Total Due
Sun, October 1 2023 16 Tishrei 5784
pURCHASES BENEFIT eTZ cHAIM