BSTYG REGISTRATION FORM ___________(year)
NAME: ______________________________ DATE OF BIRTH: _________________
ADDRESS: _________________________________________________________________________
HOME TEL: _________________ CELL: __________________ EMAIL: _____________________
SCHOOL: _____________________________________________ GRADE: _______________
PARENT/GUARDIAN NAME: _________________________________________________________
HOME TEL: _________________ CELL: __________________EMAIL: ______________________
WORK TEL: _________________ CELL/PAGER: ___________ EMAIL: ______________________
PARENT/GUARDIAN NAME: _________________________________________________________
HOME TEL: _________________ CELL: __________________EMAIL: ______________________
WORK TEL: _________________ CELL/PAGER: ___________ EMAIL: ______________________
Members of TBS? yes __ no __ If not, where ? _______________________________
1. I will not possess, consume or distribute alcoholic beverages, other than that served by the adult leadership for Jewish sacramental purposes.
2. I will not possess, use, or distribute any illegal drug or drug paraphernalia.
3. I will not smoke, consume, or distribute tobacco products.
4. I will not commit any illegal act. I understand that vandalism, disturbing the peace, or other inappropriate behavior as determined by the adult leadership will not be tolerated. I understand that I will have to pay for any damage that I cause. I understand that gambling is not allowed, except for fundraisers approved by the adult leadership.
5. I agree to refrain from inappropriate sexual behavior.
6. I will participate fully in any event I attend. I will arrive on time, remain on the premises at all times and stay until the end of the event.
7. I agree to abide by all rules set forth by the Temple Beth Sholom Youth Advisor, staff and chaperones, and to accept the consequences of violating the rules.
I have read the above rules of behavior, designed to promote the health and safety of all event participants, and fully understand them. Indicate my unqualified acceptance of these rules by my signature and that of my parent/guardian below.
Member’s Signature: __________________________ Date: ____________________
Parent/Guardian Signature: _____________________ Date: ____________________
Please mail your completed registration form to: BSTYG, Temple Beth Sholom, 228 New Hempstead Road, New City, NY 10956
I, ____________________________give permission for my son/daughter, _______________________ to attend Temple Beth Sholom Youth events. I agree not to hold Temple, TBS youth director, trip chaperones, or any of its appointees liable in case of accident, illness or injury. I understand that in case an accident, illness, or injury occurs to my child during any TBS event, every effort will be made to contact me immediately. However, if I cannot be reached or if any emergency situation arises in which time is of the essence, I give permission for my child to e treated by any hospital or by other medical professionals as chosen by a member o the Temple Beth Sholom Youth Staff or by a trip chaperone to administer medications; to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes; an to provide or arrange necessary related transportation for my child.
_____________________________ ________________________
Signature Date
Insurance Company Name: ______________________________________________________
Policy Holder: _______________________________________________________
Group Name/Number: _____________________________________________________
Physician’s Name: ______________________ Telephone #: __________________
Date of Last Tetanus Immunization: ______________________________________________________
Emergency Contact: Last Name: _________________ First Name: __________________
Telephone #: ___________________________ Relationship: _________________
Medical information that the youth director should be aware of, such as medications your child is presently taking (give details of dosage and administration), food allergies, Medication allergies, misc. allergies, medical conditions and any addition health information that we should know. All information will be kept confidential.
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Parent/Guardian Signature Date