Parent/Guardian #1 information
Street, City, State, Zip
Parent/Guardian #2 information
*** Must be someone different than who was listed above
Aunt, Uncle, Neighbor, etc...
Allergies, asthma, significant conditions.
If nothing notable, just write "None."
Kosher, vegetarian, food sensitivities/allergies
In case of medical or surgical emergency, I understand that every effort will be made to contact parents or guardians of youth group members. In the event that the family cannot be reached, I nearby give permission for the Youth Director/the Director's designee to secure all proper medical treatment for the youth group participant. I release Congregation Gates of Heaven and its designees from all responsibilities other than supervision of activities.
By writing my name, I hereby agree with the above statement.
- Synagogue property is not to be abused or damaged in any way.
- Leave a youth group activity without the permission of the Youth Director is strictly prohibited.
- NO DRUGS, ALCOHOL, OR ANY OTHER ILLEGAL SUBSTANCES are permitted at any youth group functions.
- Guests are allowed at youth group functions only with the permission of the Youth Director. Unauthorized guests will be asked to leave the event.
- Violation of these rules and/or laws may result in suspension from future youth group activities and/or legal action if warranted.
- All members will agree to refrain from any inappropriate sexual behavior.
- All members will abide by any additional rules, pertinent to a specific event, which may be announced, and will accept the consequences of their violation.
I have read the Birt Kehillah (Code of Conduct) and agree that the member will abide by its terms and conditions. I understand that any infraction or violation of the Brit Kehillah may result in immediate expulsion from an event and/or membership at the expense of the parent/guardian.
*** To be completed by youth ***
Clubs, sports, teams, etc.
If you have any questions or comments, please contact our Youth Advisors, Alyssa Fecura at email@example.com or Jen Price at firstname.lastname@example.org or call the temple office at 518-374-8173.
Membership Dues are $45. You may pay online with a check or credit card. If you choose to pay in person/send a check into the office, please make all checks payable to CGOH, Memo: GOHTY, and select the appropriate payment option.
Is usually located between the
symbols on your check.
Typically comes before the
symbols. Its exact location and number of digits varies from bank to bank.