2021-2022 Youth Group Registration Form - Form

2021-22 MJC Youth Group Registration

Youth Group registration is now open for the 2021-22 School year.

Youth group Fees are:
KATAN (Grades K-2):
MJC Members: $40 Non-Members $75

PRE-KADIMA (Grades 3-5):
MJC Members: $40 Non-Members $75

KADIMA (Grades 6 & 7):
MJC Members: $41 Non-Members $95

USY (Grades 8-12):
8th Grade:
MJC Members: $20 Non-Members $48
9th-12th Grades
MJC Members: $43 Non-Members $97

* Student's Full Name

Student's Hebrew Name

* Student's Date of Birth

* Student's Grade as of Sept. 2021

* Student's Email

Student's Cell Phone (if applicable)

* Student's Address

* City

* Postal Code

* Parent/Guardian #1 First Name

* Parent/Guardian #1 Last Name

Parent 1's Hebrew Name

* Parent/Guardian #1 Email

Parent/Guardian #1 Home Phone

* Parent/Guardian #1 Mobile Phone

Parent/Guardian #2 First Name

Parent/Guardian #2 Last Name

Parent/Guardian #2 Email

Parent/Guardian #2 Home Phone

Parent/Guardian #2 Mobile Phone

Parent 2's Hebrew Name

* Local Non-Parent Emergency Contact Name

* Emergency Contact Phone Number

* Emergency Contact Relationship to Child(ren)

Student's Insurance Company

Insurance Policy Number

Is the student a member of Marlboro Jewish Center?

Please Select OneYesNo

Which synagogue does the student belong to?

Is the student currently enrolled in any formal Jewish education?

Please Select OneYesNo

Where is the student enrolled?

EMERGENCY MEDICAL INFORMATION

* Does the student currently take any medications?

Please Select OneYesNo

Please list all medications

Please list any allergies

Please list any recent illnesses, injuries or surgeries

Please note any health/behavioral concerns or restrictions of which we should be made aware

* Waiver: I (the parent or legal guardian) permit the student named above to participate in Marlboro Jewish Center’s Youth Program. I confirm that the student is in good/normal health and has no physical or mental conditions that would interfere with full participation in the program and has my permission to engage in all available activities excepted as noted in this form above. For the safety and enjoyment of all members, I understand my child is expected to behave in an appropriate manner. Fighting, use of foul language, bullying, rough-housing and vandalism, as well as the violation of any rules explained by our staff is prohibited. Possession of any weapons, illegal or controlled substances are strictly prohibited. Should my child violate this code, I understand that s/he will be sent home at my expense, and may be barred from further youth group activity at the discretion of the Youth Director. Finally, I agree not to hold MJC responsible in case of sudden illness or accident. Should such an emergency arise, I understand that every effort will be made to contact me. However, if I cannot be reached, I give permission for my child to be treated by a medical professional in my absence. I understand the doctor will decide the most appropriate treatments for my child.

Waiver: I (the parent or legal guardian) permit the student named above to participate in Marlboro Jewish Center’s Youth Program. I confirm that the student is in good/normal health and has no physical or mental conditions that would interfere with full participation in the program and has my permission to engage in all available activities excepted as noted in this form above. For the safety and enjoyment of all members, I understand my child is expected to behave in an appropriate manner. Fighting, use of foul language, bullying, rough-housing and vandalism, as well as the violation of any rules explained by our staff is prohibited. Possession of any weapons, illegal or controlled substances are strictly prohibited. Should my child violate this code, I understand that s/he will be sent home at my expense, and may be barred from further youth group activity at the discretion of the Youth Director. Finally, I agree not to hold MJC responsible in case of sudden illness or accident. Should such an emergency arise, I understand that every effort will be made to contact me. However, if I cannot be reached, I give permission for my child to be treated by a medical professional in my absence. I understand the doctor will decide the most appropriate treatments for my child.

* Today's Date

* Media Permissions

Please Select OneI give permission for my child(ren)s photograph or video image to be published in any form of media via print or electronicI DO NOT give permission for my child(ren)s photograph or video image to be published in any form of media via print or electronic

* We confirm that we both (student and parent/legal guardian) have read the Hagalil USY and Kadima Code of Conduct. We understand the policy and consequences.

We confirm that we both (student and parent/legal guardian) have read the Hagalil USY and Kadima Code of Conduct. We understand the policy and consequences. Click here to read the Hagalil USY and Kadima Code of Conduct.

* Today's Date

PAYMENT

* Which group is the student registering for?

Total Amount: