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Summer 2024 Youth Group

Summer 2024 Youth Group
Youth #1 Information
Youth #2 Information
Parent Information
If no parent 2 please put N/A in the box.
If no parent 2 please put N/A in the box.
If no parent 2 please put N/A in the box.
If address differs from parent 1 please put information in the box. If address is same please put N/A.
Emergency Contacts
Parents are always contacted first, however, in case of illness, accident or injury please list additional people below who can be contacted.
Please Include:
Full name
Relationship to your child(ren)
Phone #
Include the following information:
Name of Insured
Name of Insurance Company
Policy #
Include the following information:
Doctor Name & Phone Number
Parent Consent & Release
I give my child(ren) permission to take part in the Temple Beth Emet Youth Group for summer 2024. As the parent/legal guardian, I hereby release Temple Beth Emet and its staff of any and all liabilities incident to and arising out of all Temple Beth Emet Youth Programs. In addition, I hereby give permission to the group advisor to secure proper medical treatment in case of an emergency for my child(ren) as named above in the event I cannot be reached.
Both parents need to sign (even if parents are separated or divorced). If there is no parent 2 please put N/A. 
Payment Agreement
Full Summer: $100
Weekly: $18 per session
Credit Card & Debit Card Payment Information
(Credit card payments will incur a 3% convenience fee, there are no additional fees for debit card payments)
Tue, January 21 2025 21 Tevet 5785