USY and Kadima Membership Form 2022-23 - Form

Section A: Family Contact Information

* First Name (Primary)

* Last Name (Primary)

* Email (Primary)

* Phone (Primary)

* Relationship to Student(s) (Primary)

* Street Address (Primary)

* City (Primary)

* State (Primary)

* ZIP (Primary)

* Is there a secondary contact?

Please Select OneNoYes, at the same address as the primary contactYes, but at a different address than the primary contactIf there is a secondary contact, all emails and mailings will go to both contacts. In case of urgent need, the primary contact will be notified first

* First Name (Secondary)

* Last Name (Secondary)

* Email (Secondary)

* Phone (Secondary)

* Relationship to Student(s) (Secondary)

* Street Address (Secondary)

* City (Secondary)

* State (Secondary)

* ZIP (Secondary)

* Emergency Contact Name

* Emergency Contact Phone

* Emergency Contact Relationship

Section B: Student Enrollment Information

* How many children (6th-12th grade) are being enrolled for USY or Kadima for the 2022-2023 year?

Student 1 Information

* Student 1 First Name

* Student 1 Last Name

* Student 1 Birthdate

* Student 1 Grade in 2022-2023 School Year

* Student 1 Secular School Name

Student 1 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 1 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 1 Allergies or Medications

Please Select OneNoYesDoes your child have allergies or medications we need to know about?

Student 1 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Student 2 Information

* Student 2 First Name

* Student 2 Last Name

* Student 2 Birthdate

* Student 2 Grade in 2022-2023 School Year

* Student 2 Secular School Name

Student 2 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 2 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 2 Allergies or Medications

Please Select OneNoYesDoes your child have allergies or medications we need to know about?

Student 2 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Student 3 Information

* Student 3 First Name

* Student 3 Last Name

* Student 3 Birthdate

* Student 3 Grade in 2022-2023 School Year

* Student 3 Secular School Name

Student 3 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 3 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 3 Allergies or Medications

Please Select OneNoYesDoes your child have allergies or medications we need to know about?

Student 3 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Student 4 Information

* Student 4 First Name

* Student 4 Last Name

* Student 4 Birthdate

* Student 4 Grade in 2022-2023 School Year

* Student 4 Secular School Name

Student 4 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 4 Phone (if applicable)

Information will not be shared publicly. Students will not be contacted independently from parents.

* Student 4 Allergies or Medications

Please Select OneNoYesDoes your child have allergies or medications we need to know about?

Student 4 Allergy/Medication Details

Please describe allergies and medications with dosage and timing.

Section C: Release Forms

Medical emergency -In the event of a medical emergency or accident, or the possibility that a serious situation may develop, TCS reserves the right to call 911 and to move the child by ambulance to the nearest full medical facility. I hearby authorize such physician or emergency facility to treat my child in any emergency situation until such time as I can be reached for specific permission.

* Medical Release: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

Media Release

Media Authorization - We may use your child's name, photograph, or video in direct mail pieces or other forms of promotion. Occasionally TCS may supply information to the local community newspapers and TCS electronic media (including but not limited to: TCS website, TCS Bulletin, TCS Social Media about programs in which TCS students participate. I agree to release TCS, the photographer, their offices, employees, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use.

* Media Release

Please Select OneI grant permission for my child's image to be usedI do not grant permission for my child’s image to be used

Section D: Financial Agreement

TCS USY Membership FINANCIAL AGREEMENT

I hereby enroll my child(ren) in The Conservative Synagogue “TCS” USY Membership. I understand that all fees are payable when billed. I further understand and agree to the following:

USY Membership fees are $60 per child.
Kadima Membership fees are $40 per child

Fees are NON REFUNDABLE even if child does not attend.

• I will be responsible for the total membership fees regardless of absences or my voluntary withdrawal of my child(ren) from the program for any reason.
• I understand that USY Membership is only available to TCS members. I agree to maintain my membership in good standing.

TCS reserves the right to cancel any event at any time due to insufficient enrollment.

Financial agreement: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

Section E: Payment Information

Total Amount