2022-2023 KCUSY/Kadima Membership - Form - Congregation Beth Shalom

Section A: Family Contact Information

* First Name (Parent/Guardian 1)

* Last Name (Parent/Guardian 1)

* Email (Parent/Guardian 1)

* Phone (Parent/Guardian 1)

* Relationship to Student(s) (Parent/Guardian 1)

* Street Address (Parent/Guardian 1)

Street Address Line 2 (Parent/Guardian 1)

* City (Parent/Guardian 1)

* State (Parent/Guardian 1)

* ZIP (Parent/Guardian 1)

* Is there a secondary contact?

Please Select OneNoYes, at the same address as the primary contactYes, but at a different address than the primary contactIf there is a secondary contact, all emails and mailings will go to both contacts. In case of urgent need, the primary contact will be notified first.

* First Name (Secondary)

* Last Name (Secondary)

* Email (Secondary)

* Phone (Secondary)

* Relationship to Student(s) (Secondary)

* Street Address (Secondary)

Street Address Line 2 (Secondary)

* City (Secondary)

* State (Secondary)

* ZIP (Secondary)

* Emergency Contact Name

* Emergency Contact Phone

* Emergency Contact Relationship

Section B: Student Enrollment Information

* Do you require financial aid?

Please Select OneYesNoPlease contact Ben Novorr, Director of Youth & Family Programming, HERE if you need financial help.

* How many children in grades 6th-12th will you be enrolling in KCUSY/Kadima for the 2022-2023 year?

Student 1 Information

* Student 1 First Name

* Student 1 Last Name

* Student 1 Birthdate

Student 1 Nickname (if applicable)

* Student Gender

Student Preferred Pronoun

Kadima Membership (Grades 6th-8th)

KCUSY Membership (Grades 9th-12th)

* Student 1 Secular School Name

Student 1 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 1 Phone (if applicable)

Information will not be shared publicly.

At Congregation Beth Shalom we strive to establish an environment in which all young people may thrive. Information you provide about your child’s strengths and challenges will assist in our efforts to accommodate and provide for those needs. Any information you provide will be held in the strictest confidence and will be shared only as necessary to provide your child with a quality experience.

* Student 1 Medical

Please Select OneNoYesDoes your child take any medications, have any illness or chronic condition that school personnel needs to be aware of (i.e., asthma, dietary restrictions, allergies, ADD/ADHD, hearing, vision, speech)?

Student 1 Medical Details

If you answered yes on the question prior, please describe.

Please note: Congregation Beth Shalom cannot be responsible for administering any daily medications to any student. Please administer your child's medication at home, before your child comes to CBS Programming. If you child has severe allergies, please supply any needed rescue medications. Parents will receive a phone call if their child requests any over the counter pain medications.

What else would you like KCUSY/Kadima to know about your child?

Any information shared will be strictly confidential.

Student 2 Information

* Student 2 First Name

* Student 2 Last Name

* Student 2 Birthdate

Student 2 Nickname (if applicable)

Student Gender

Student Preferred Pronoun

Kadima Membership (Grades 6th-8th)

KCUSY Membership (Grades 9th-12th)

* Student 2 Secular School Name

Student 2 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 2 Phone (if applicable)

Information will not be shared publicly.

At Congregation Beth Shalom we strive to establish an environment in which all young people may thrive. Information you provide about your child's strengths and challenges will assist in our efforts to accommodate and provide for those needs. Any information you provide will be held in the strictest confidence and will be shared only as necessary to provide your child with a quality experience.

* Student 2 Medical

Please Select OneNoYes

Does your child take any medications, have any illness or chronic condition that school personnel needs to be aware of (i.e., asthma, dietary restrictions, allergies, ADD/ADHD, hearing, vision, speech)?

Student 2 Medical Details

If you answered yes on the prior question, please describe.

What else would you like KCUSY/Kadima to know about your child?

Any information will be strictly confidential.

Student 3 Information

* Student 3 First Name

* Student 3 Last Name

* Student 3 Birthdate

Student 3 Nickname (if applicable)

Student Gender

Student Preferred Pronoun

* Kadima Membership (Grades 6th-8th)

KCUSY Membership (Grades 9th-12th)

* Student 3 Secular School Name

Student 3 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

Student 3 Phone (if applicable)

Information will not be shared publicly.

* Student 3 Medical

Please Select OneNoYes

Student 3 Medical Details

If you answered yes on the prior question, please describe.

What else would you like KCUSY/Kadima to know about your child?

All information will be held in the strictest confidence.

Student 4 Information

* Student 4 First Name

* Student 4 Last Name

* Student 4 Birthdate

Student 4 Nickname (if applicable)

Student Gender

Student Preferred Pronoun

* Student 4 Secular School Name

Student 4 Phone (if applicable)

Information will not be shared publicly.

Student 4 Email (if applicable)

Information will not be shared publicly. Parents will be copied on all communication to students.

* Kadima Membership (6th-8th)

KCUSY Membership (Grades 9th-12th)

* Student 4 Medical

Student 4 Medical Details

If you answered yes on the prior question, please describe.

What else would you like KCUSY/Kadima to know about your child?

Section C: Release Forms

By signing my name below, my child(ren) have permission to participate in the KCUSY/Kadima through Congregation Beth Shalom. I hereby authorize the Programming Director, or person designated by the Programming Director, to obtain emergency medical care for my child(ren) in the event such care is indicated. I give my permission for my child(ren) to receive emergency medical care by any nurse, doctor, paramedic or member of a medical staff of a hospital licensed by the state of Kansas. I understand that every effort will be made to notify a parent/guardian prior to treatment.

I certify that my child(ren) is(are) in good physical health. They have my permission to participate in all activities that are part of KCUSY/Kadima.

I release Congregation Beth Shalom and United Synagogue Youth and their agents from any liability.

The possession or use of alcohol, drugs, and/or tobacco products as well as behavior that endangers the safety of my child/ren or others, will result in my child being sent home from programs. If an offense does occur, I accept responsibility for my child/ren's actions and support the staffs discipline decisions.

* Medical & Safety Release: Enter your name below

By typing my name, I confirm I have read, understand and agree to the above.

* Doctor's Name

* Doctor's Phone Number

* Health Insurer

* Policy Number

* Group Number

Media Release

From time to time your child(ren)’s photo may be taken in our classrooms or special events. We use these photos on the synagogue website, on our synagogue display boards, in the weekly Connect email, the monthly Scroll newsletter, as well as our Facebook page and other publicity materials.

* I give my permission for my child(ren)'s photo to be used:

Please Select OneOn any materialsI do NOT give my permission for my child’s image to be used

Section E: Payment Information

Total Amount