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Youth Group Membership Form
Please use one form per child.
Check one: □ Machar (K-3) □ Chaverim (4-5) □ Kadima (6-7) □ USY (8-12)
Member Full name
City, State, Zip
Parent Mobile or cellular phone
Home e-mail address
Member e-mail address
Member Cell Phone
Emergency and Medical Information
In case of emergency, contact
Emergency contact’s phone
PARENT’S AUTHORIZATION AND MEDICAL RELEASE STATEMENT
By checking this box, I do request and authorize Congregation Beth El to permit my child
to attend and participate in any youth activities in the Synagogue and outside the
Synagogue, including transportation that is involved in the event. I accept full
responsibility for his/her actions, including the illegal use of drugs or other substances,
while so engage and release Congregation Beth El, employees, and chaperones, etc., from
any liability. In case of emergency, I do give permission to the physician selected by the
Youth Director, Youth Advisor, or adult in charge of the event, to hospitalize, secure proper
treatment for and to order injection, anesthesia or surgery for my child.
By checking this box, I give my permission for photographs, slides, videos or audiotapes to be taken
of my child to be used for our calendar, website, public relations purposed and the promotion of
Congregation Beth El and the Youth Department. Understand that the above may be used by the
mass media for newspaper or television without my consent for usage.
By checking this box, I understand the $36 membership fee will be included in my Beth El bill and
will be deducted from my next payment.
Return the completed form to
Congregation Beth El Attn: Youth Dept.
8000 Main Street Voorhees NJ 08043