Youth Department Membership 2024-25

We are so excited for you to join our community youth group, the Jewish Youth Network. Membership is open to youth in 3rd-12th grade. We are affiliated with HAMAKOM, but membership at HAMAKOM is not required for Jewish Youth Network Membership.

If you have more than one child in JYN, you can include them all in this form. If you were not a member of the Jewish Youth Network last year or the year before, please fill out the entirety of this membership form.

If you have any questions, please contact Michelle Greenberg, Director of Youth Engagement, at mgreenberg@jynla.org.

Please make sure you are logged into your ShulCloud account before filling out the form.

* Has the participant's information changed since August 2023?

Please Select OneYesNoInsurance, emergency contact, parent/guardian info, etc. Please note you will be asked to fill out their basic information with DOB, grade, school name, etc regardless.

* Has the parent/guardian information changed since Aug 2023?

Please Select OneYesNo

Child #1 Info

* Child #1 First Name

* Child #1 Last Name

Child #1 Gender

MaleFemaleNon-binary

Child #1 Cell Number (if applicable)

Child #1 Email Address (if applicable)

* Child #1 Date of Birth

(MM/DD/YYYY)

* Child #1 Age as of 08/2024

* Child #1 Grade (in Aug/Sept. 2024)

* Child #1 School Name

* Child #1 High School Graduation Year

* Do you have a SECOND child to add?

Please Select OneYesNo

Child #2 Info

* Child #2 First Name

* Child #2 Last Name

* Child #2 Gender

MaleFemaleNon-binary

Child #2 Cell Number (if applicable)

Child #2 Email Address (if applicable)

* Child #2 Date of Birth

MM/DD/YYYY

* Child #2 Age as of 08/2024

* Child #2 Grade (in Aug/Sept 2024)

* Child #2 School Name

* Child #2 High School Graduation Year

* Do you have a THIRD child to add?

Please Select OneYesNo

Child #3 Info

* Child #3 First Name

* Child #3 Last Name

Child #3 Cell Number (if applicable)

Child #3 Email Address (if applicable)

* Child #3 Age as of 08/2024

* Child #3 Grade (in Aug/Sept 2024)

* Child #3 School Name

* Child #3 High School Graduation Year

Parent/Guardian Info

* Parent/Guardian 1 (First Name)

* Parent/Guardian 1 (Last Name)

* Family Mailing Address

Address, City, Zip Code

* Parent/Guardian 1 (Cell Phone)

* Parent/Guardian 1 (Email)

* Parent/Guardian 2 (First Name)

* Parent/Guardian 2 (Last Name)

* Parent/Guardian 2 (Cell Phone)

* Parent/Guardian 2 (Email)

Emergency Contact Info

* Emergency Contact (First Name)

* Emergency Contact (Last Name)

* Emergency Contact (Cell Phone)

* Relationship

Child #1 Medical Info

The information on this form is accurate, complete, and all-inclusive, to the best of my knowledge. I understand the importance of keeping this information accurate and agree to contact the Director of Youth Engagement any Youth Department program that my child will attend if there is a change of any kind whatsoever in their medical condition.

* Medical Insurance Provider

* Medical Insurance Policy #

* Participant's Primary Care Doctor Name

* Participant's Primary Care Doctor Phone Number

* Is the medical information the same for all children you are registering?

Please Select OneYesNo

Child #2 Medical Insurance Provider

Child #2 Medical Insurance Policy Number

Child #2 Primary Care Doctor

Child #2 Primary Care Doctor Phone Number

Child #3 Medical Insurance Provider

Child #3 Medical Insurance Policy Number

Child #3 Primary Care Doctor Name

Please explain any medical conditions that your child/ren has that we should be aware of:

Please list any allergies your child/ren has that we should be aware of:

Youth Code of Conduct

The Jewish Youth Network is an extension not only of our congregation and community but part of an international Jewish youth organization. There are certain guidelines, therefore, that all members must follow. These rules are for the safety of our members and the support of our programs. Upon joining, each participant must sign a form stating their understanding of the policies. Non-compliance may result in removal from any program or event whether it be chapter or regional and may jeopardize future attendance at programs and events. Included in the rules are the following:

No smoking, drugs, or alcohol are allowed at any event.

No physically destructive behavior will be tolerated at any event, including that which is harmful to material or injurious to others.

No theft of any kind will be tolerated.

Use of negative, tasteless or hurtful language will not be tolerated. In their language and behavior, members will treat others (including chaperones, staff and other members) with respect.

Members will be respectful of the tenets of Conservative Judaism. These include, but are not limited to, the laws of Kashrut and Shabbat, when applicable, as well as not conducting Youth Department business including but not limited to planning, meetings, etc. on Shabbat or Chag.

Situations where members are non-compliant with these policies will be handled as follows:

1st Offense: Speak with the Youth Director and notify parents/guardians following the incident.

2nd Offense: Parent/guardian contacted for immediate pick-up.

3rd Offense: Member will not be permitted to return without a customized behavior contract signed by parents/guardians, member, advisor, and Youth Director.

*If non-compliant behaviors continue, member will not be permitted to participate in Youth Department and USY regional events for the remainder of the year.

*If offense is severe, whether 1st offense or repeat offense, the situation may be handled differently than the order listed above.

* This signature confirms that parent/guardian and participant have reviewed and agreed to these terms

This signature confirms that parent/guardian and participant have reviewed and agreed to these terms

* Parent/Guardian Signature

* Participant Signature (include all participant signatures in this box if you have multiple)

Publicity Release for Minors

We occasionally submit pictures of our activities for publication and/or post them on our website. Please select your permission to publish pictures of your child. I hereby consent to the publication of photographs, quotes, and video of my child on the Youth Department website and social media sites for the duration of my child's enrollment. Please note if you are okay with pictures and video and name listing, or if you would like it withheld.

* Publicity Release for Minors

YesNo

* Transportation Consent (Enter Parent/Guardian's Full Name to Consent)

I acknowledge and accept the youth department's policies to use licensed drivers over the age of 21 at all times. With full understanding of the policy and the risks involved, I give permission for this child to ride in a properly insured vehicle driven by a licensed driver over the age of 21.

* Medical Consent (Enter Parent/Guardian's Full Name to Consent)

I consent and give permission for my child to attend and participate in all trips and activities arranged by the Youth Department and Far West USY/KADIMA for which they are registered. I certify that my child is physically and psychologically able to participate in all such activities.

In case of emergency, I authorize you, as my agent, and at my sole cost and expense, to engage appropriate healthcare providers to administer, prescribe, and/or direct administration of any medication, other medical treatment, care, surgery, hospitalization, or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions.

* Release & Indemnification (Enter Parent/Guardian's Full Name to Consent)

I expressly release and indemnify the Youth Department and it’s officers, directors, agents, and employees, and hold the Youth Department and its officers, directors, agents, and employees free and harmless, from any and all liability, charges, claims, costs and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with acceptance and participation of my child in the Youth Department's activities. This release and indemnification is unconditional and without reservation of any kind for such acts or omissions that arise out of your intentional or negligent wrongdoing, and where there is no fault by my child. I am fully responsible if I fail to disclose any pertinent information.

I allow the Youth Department to use any photographs of my children taken during any of the Youth Department sponsored programs/events for usage in promotional aspects.

* Please Enter Today's Date

* Membership type

3rd-6th Grade (HAMAKOM Member/Non-member) - $75

7th-12th Grade (HAMAKOM Member-Non-member) - $90Please select the appropriate membership for your child

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