Youth Group Membership Form 24/25

CBI Youth Dept Membership Form 2024-2025

Membership forms and dues are good for one school year lasting from July 1st to June 30th. Forms must be updated each year and dues paid for each year. Please complete a separate form for each participant. There is a form at the beginning that needs to be printed and signed. You may scan the signed copy, upload a photo, and email it to youth@cbi18.org .

Download the CBI Youth Group Release & Authorization and Code of Conduct forms at the link below (they're in one file):

CLICK HERE

If you have any trouble accessing the form or questions, email youth@cbi18.org and a copy can be sent via email.

It is expected that you and your child (the "we" in the form) will go over the Release & Authorization and Code of Conduct together and your child will abide by this policy. As a parent, please initial as you go through the forms (the "I" in the form). There is space for the participant to sign at the bottom of each document. It is recommended both parents (if applicable) familiarize themselves with the rules, even though only one is required to initial and sign. The forms are geared toward our USY program, but please fill it out for younger children regardless.

You may scan the signed copy or upload a photo.

Upload a signed copy of the Code of Conduct form

Are you current members of Congregation B'nai Israel? If not, where are you affiliated?

* Parent/Guardian 1 First Name

* Parent/Guardian 1 Last Name

* Parent/Guardian 1 Cell Number

* Parent/Guardian 1 Email

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Cell Number

* Parent/Guardian 2 Email

Youth First Name

Youth Last Name

Youth Email (If they have one)

Youth Phone (if they have one)

Youth Address

Youth City

Youth State

Youth Zip

Youth Date Of Birth

Youth Gender

Grade in Sept 2024

Youth Allergies

Please indicate if life threatening allergy, mild allergy, sensitivity, or other.

Other Medical Conditions

Medications

Youth Medical/Health Insurance Company Name

Medical/Health Insurance Policy #

Medical/Health Insurance Group #

Primary Physician Name

Primary Physician Phone Number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Cell Number

Emergency Contact Email

Emergency Contact Relationship to Youth

Which dues category does this participant fall into?

Total

Sat, December 21 2024 20 Kislev 5785

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