LIBERTY Membership 18-19 - Form

2018-19 Temple Beth El LIBERTY Youth Group Registration Form

Welcome to the online LIBERTY Youth Group Registration!

LIBERTY (Life In Beth El Reform Temple Youth) is for youth in grades 8-12. The teen-elected LIBERTY board, plans, organizes and implements programs with assistance from TBE staff. From awesome social and cultural programs to fun weekends with Jewish teens from around the Southeast, LIBERTY offers teens the best way to get involved, make life-long friendships and set the course for their own Jewish journeys! The membership fee to join LIBERTY is $65 per person . Membership is required to participate in any overnight LIBERTY event and includes the registration fee for the next overnight event (Currently the Elections and Graduation Lock-In on 5/31) and discounted rates for any other events that include a cost. Please do not let cost be a barrier to joining LIBERTY. We are happy to discuss financial assistance with your family. If you have questions, please contact Sam Swire at 704-749-3049 or email sswire@templebethel.org.

If any required field is not relevant to your family, type "NA."

Parent Information

* Parent 1 First Name

* Parent 1 Last Name

* Parent 1 Email

* Parent 1 Cell Phone

Home Phone

Parent 1 Work Phone

* Address

Address (Line 2)

* City

* State

* Zip

* Parent 2 First Name

If not applicable, please type NA

* Parent 2 Last Name

If not applicable please type NA

* Parent 2 Email

If not applicable please type NA.

* Parent 2 Cell Phone

If not applicable please type NA.

Please reach out to me about volunteering to support Youth Programs at TBE

YesNo

Youth Information

SingleMarriedDivorcedOther

If other, please explain

* Does your family have a current TBE Membership

Please Select OneYesNo

* Child's Full Name and Date of Birth

* Child Date of Birth

* Child's Grade

* Child's School

Child 2 Full Name

Child 2 Date of Birth

Child 2's Grade

Child 2's School

Child 3 Full Name

Child 3 Date of Birth

Child 3's Grade

Child 3's School

Publications and Photos/Videos

Temple Beth El may publish individual photos/videos of your child(ren) in Temple Beth El publications, in CJN or other newspapers, on the website, or other social media with secure and restricted public access, and on school bulletin boards. If you DO NOT wish to have your child's photograph published, please check this box. Note: All students may appear in photos/videos that showcase whole classes or multiple student groups.

Children's Medical Information and Release

Please complete the answers to the following questions for all children being registered. Your answers are held in complete confidence with the Director of Education. Being as honest and thorough as possible allows us to provide the best environment for your child(ren).

* Does your child(ren) have any allergies, food allergies, or food they cannot eat

Please Select OneYesNo

Please list all allergies or foods that must be avoided

If you are registering more than one child, please indicate which child you are referring to.

Any special medical concerns (allergies, medications, etc.) should we know about? Is it necessary to keep emergency medication in the office? If so, what medication and how is it administered?

If you are registering more than one child, please indicate which child you are referring to.

Please describe any special needs your child has

If you are registering more than one child, please indicate which child you are referring to.

Please describe any accommodations your child(ren) requires to be successful during Youth Group activities

If you are registering more than one child please indicate which child you are referring to.

PERMISSION FOR EMERGENCY MEDICAL TREATMENT

* Name of Child(ren)'s Physician

If registering more than one child, and they have different primary physicians, please indicate which child sees which physician.

* Physician Phone Number(s)

* Insurance Carrier

* Insurance Policy Number

* Name of Insurance Policy Holder

I/we will indemnify, save harmless and defend Temple Beth El, its officers, directors, agents, and employees, from all liability from loss, damage, or injury to persons or property in any manner arising out of or incident to the performance of this agreement including without limitation all consequential damages and/or attorney's fees. in the event of a medical emergency and I/we cannot be reached, I/we hereby give permission to the physician selected by the Temple agent to hospitalize and secure proper treatment for my child(ren) as named herein.

* Parent/Guardian E-Signature

In the event your child becomes ill or injured and we are unable to reach a parent, please provide two local emergency contacts other than parents. We will always attempt to reach parents first.

* Emergency Contact 1 Name

* Emergency Contact 1 Relationship

* Emergency Contact 1 Phone Number

* Emergency Contact 2 Name

* Emergency Contact 2 Relationship

* Emergency Contact 2 Phone Number

* Number of Children you are registering for $65 each

Please consider making an additional donation to help subsidize our TBE Youth programs:

Enter the dollar amount you would like to donate.