Youth Registration

Membership Fee *		$ 25.00 Makor (Grades 3rd- 5th) $ 35.00 Kadima (Grades 6th-8th) $ 50.00 USY (Grades 9th-12th)
		I will send payment by check

Email Address *

USY Registration - Parent Information

Parent or Guardian First and Last Name 1 *
Parent or Guardian Cell Number 1 *
Parent or Guardian Work Number 1
Parent or Guardian First and Last Name 2
Parent or Guardian Cell Number 2
Parent or Guardian Work Number 2
Home Phone Number *
Street Address (Primary) *
City *
Postal Code *
Emergency Contact Name 1 *
Emergency Contact Relationship 1 *
Emergency Contact Phone Number 1 *
Emergency Contact Name 2 *
Emergency Contact Relationship 2 *
Emergency Contact Phone Number 2 *
Family Doctor *
Family Doctor Phone Number *

Fill in if above is also the billing name and address on the credit card

USY Registration - Student Information

Student First Name *
Student Last Name *
Gender *	Female Male ( unselect )
Hebrew Name *
Birth Date *	-month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -day- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   -year- 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
School *
Grade (as of September 2012) *	- select - K 1st. 2nd. 3rd. 4th. 5th. 6th. 7th. 8th. 9th 10th 11th 12th
You are *	Jewish by Birth Jewish by Conversion Non Jewish ( unselect )
Your mother is *	Jewish by Birth Jewish by Conversion Non Jewish ( unselect )
Your Father is *	Jewish by Birth Jewish by Conversion Non Jewish ( unselect )
Medical Insurance Company *
Medical Insurance Policy Number *
Special Conditions	In order to enable the youth department to be of maximun service to your child, please inform us if there are any circumstances or conditions of which we should be aware, i.e. special needs, emotional problems, allergies, health restrictions, etc. (All information given here will kept strictly confidential.) If you prefer, you may contact the Youth Director directly regarding any of the above issues.