Fillable Printable Temple Solel Youth Group Membership Application 2015 - 2016

Temple Solel Youth Group Membership Application 2015 - 2016

TEMPLE SOLEL YOUTH GROUP MEMBERSHIP APPLICATION

2015-2016

Please circle one: TIKKUN (7

- 12

grade); OLIM (9

– 12

grade)

Child Name: ____________________ Grade (Secular School) _____________(School)__________________

Address and Zip: ______________________________________________________________________

Home Phone: ( )____________________________

Parent 1 Name: _______________________________ Parent 1 Email: ___________________________

Parent 1 Work Phone: ( ) _______________________ Parent 1 Cell Phone: ( )____________________

Parent 2 Name: ___________________________ Parent 2 Email: ___________________________

Parent 2 Work Phone: ( )_______________________ Parent 2 Cell Phone: ( )____________________

Child’s Email Address: _________________________ Child’s Cell Phone: ( ) ___________________

FOR OLIM ONLY:

Would you like to be contacted by text messaging for all upcoming Youth Group events? ❑ YES ❑ NO

TRANSPORTATION FORM FOR DRIVERS

To ensure the safety and well being of all members attending a youth event, we must have proof of insurance as

well as the following information on file at the temple:

1. You must possess a current driver’s license (high school aged drivers must provide a copy of their current

driver’s license and record of convictions).

State License Number: ______________________ Expiration Date: _____________

2. Name of Insurance Company: _____________________________________

Effective Dates: __________________________________________

*Exact amount of Bodily Injury Coverage (Must have a minimum of

$100,000/$300,000) _______________________________________

*Exact amount of Personal Property Coverage (Must have a minimum of

$50,000) _________________________________________________

3. Your vehicle must be well maintained with all safety equipment in working order.

NUMBER OF SEAT BELTS __________________

4. Vehicle Make: __________________ License #: ____________________

I understand the above requirements and will serve as a youth group driver.

Signature: _________________________________ Date: ________________________

Phone: ( ) ________________________________

TRIP SLIP

I give my permission for ___________________________________ to go to all scheduled activities with Temple Solel’s

Youth Groups. The specified Temple Solel Youth Group advisor will supervise all events. I understand Temple Solel

will provide qualified drivers with adequate insurance coverage and assure my child will wear a seat belt.

Signature of Parent/Guardian ________________________________ Date: __________________________

EMERGENCY MEDICAL FORM

CHILD’S NAME: _______________________________ BIRTHDATE: ____________________________

PARENTS’ NAMES: ___________________________________________________________________________

ADDRESS: ____________________________________ HOME PHONE: ( ) _______________________

CITY, ZIP _____________________________________

PARENT 1 WORK PHONE: ( ) __________________ PARENT 1 CELL PHONE: ( ) _____________

PARENT 2 WORK PHONE: ( ) __________________ PARENT 2 CELL PHONE: ( ) _____________

IN THE EVENT OF AN EMERGENCY, WHEN I AM NOT AVAILABLE, PLEASE CONTACT:

NAME: _______________________ HOME: ( ) _____________________ CELL: ( ) _____________________

ATTENDING PHYSICIAN: ____________________________ PHONE: ( ) _____________________________

I HEREBY AUTHORIZE TEMPLE SOLEL TO OBTAIN NECESSARY EMERGENCY CARE FOR MY CHILD

SIGNATURE OF PARENT/GUARDIAN _______________________________________________________

DOES YOUR CHILD HAVE ANY KNOWN ALLERGIES? YES ____ NO ____

PLEASE EXPLAIN: __________________________________________________________________

DOES YOUR CHILD HAVE ANY KNOWN ILLNESS OR CONDITION? YES ____ NO ____

PLEASE EXPLAIN: __________________________________________________________________

IS YOUR CHILD UNDER ANY MEDICAL RESTRICTIONS? (Sports, Dancing, Field Trips, Handicaps, etc.?)

YES ____ NO ____

PLEASE EXPLAIN: __________________________________________________________________

IS THERE ANY MEDICATION YOUR CHILD MUST TAKE DURING THE DAY? YES* ___ NO ___

PLEASE EXPLAIN: __________________________________________________________________

*A SEPARATE RELEASE FORM NEEDS TO BE COMPLETED BEFORE THE YOUTH GROUP ADVISOR

CAN ADMINISTER ANY MEDICATIONS

PLEASE SHARE WITH US ANY SPECIAL NEEDS YOUR CHILD MAY HAVE (i.e. shyness, separation anxiety, etc.)

_________________________________________________________________________________________________

IF A CHANGE IN YOUR CHILD’S HEALTH SHOULD OCCUR DURING THE SCHOOL YEAR AFFECTING THE

ABOVE INFORMATION, PLEASE NOTIFY THE YOUTH GROUP DIRECTOR.

SIGNATURE OF PARENT/GUARDIAN ______________________________________________________________

*****Authorization and Consent to Treat a Minor*****

In consideration of special benefits of the special activities afforded by Temple Solel, I hereby permit said child to

participate in Temple Solel’s Youth Program. I hereby release the said Temple and its participating member and

employees from any liability whatever to the undersigned resulting from, or in any manner arising out of any injury or

damage which may be sustained by the said child on account of his/her participation in said activity, or in the

transportation connection therewith.

I further agree that in case any action is brought against Temple Solel, their participating members or employees, for or on

behalf of the aforementioned child or on account of any injury during his/her participation in the above mentioned

activities, I will indemnify them and hold them harmless from any judgment recovered in any such action over and above

the amount of said liability insurance.

I/We the undersigned parent(s)/guardian(s) of ________________________ DO HEREBY AUTHORIZE Temple Solel

as agent(s) for the above signed to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or

treatment and hospital care which is deemed advisable by, and is rendered under the Medicine Practice Act on the medical

staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said

hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment of hospital care being

required, but is given to provide authority and power on the part of my/our aforesaid agent(s) to give specific consent to

any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his best

judgment may deem advisable, pursuant to the provision of Section 25.8 of the Civil Code of California.

I/We hereby authorize any hospital which has provided treatment to the above named minor pursuant to the provisions of

Section 25.8 of the Civil Code of California to surrender physical custody of such minor to my/our above name agent(s)

upon the completion of treatment. This authorization is given pursuant to the Section 1283 of the Health and Safety Code

of California. I/We also release Temple Solel and their representatives from all responsibilities of mishaps which may

befall the above named individual. I/We certify that the above named individual(s) is physically able to participate in

Temple Solel’s Youth Program and release Temple Solel and their representatives from any and all liabilities whatsoever

which may arise from his/her participation in the Youth Program of Temple Solel.

It is my further understanding that the above named individual will observe all the rules and regulations as stated by the

Youth Director of Temple Solel and Her authorized representatives.

THIS AUTHORIZATION SHALL REMAIN IN EFFECT FROM

AUGUST 15, 2015 – AUGUST 31, 2016

Parent 1 Signature _____________________________________________________

Home Phone ( ) _______________________________ Work Phone ( ) _______________________________

Parent 2 Signature _____________________________________________________

Home Phone ( ) _______________________________ Work Phone ( ) _______________________________

Legal Guardian’s Signature ______________________________________________

Home Phone ( ) _______________________________ Work Phone ( ) _______________________________

PERMISSION TO RIDE WITH HIGH SCHOOL DRIVERS

I give my son/daughter, _____________________________, permission to ride with another OLIM member, who has

permission from the youth advisor, to or from any OLIM activity during the 2015 – 2016 school year. The youth advisor

will be sure that all drivers have turned in the information above and have a valid California Driver’s license. I

understand that the OLIM director will have a copy of that driver’s license and records on file and will use his discretion

when designating drivers. I agree to hold Temple Solel and OLIM free of any liability.

Signature: _______________________________________ Date:_____________________________________

Phone: ( ) ____________________________________

TEMPLE SOLEL YOUTH PROGRAM CODE OF CONDUCT

Code of Conduct:

• I will not posses, consume, or distribute alcoholic beverages, other than that served by adult leadership for Jewish

sacramental purposes, even if I am of legal drinking age.

• I will not possess, use, or distribute any illegal drug or drug paraphernalia.

• I will not smoke or consume or distribute tobacco products at any time during events.

• I will participate fully and remain in the designated zones for the entire event unless otherwise agreed upon by the

youth director(s).

• I will not bring or use a weapon, firearm, or anything that could be used as a weapon.

• I will not commit any illegal act. I understand that vandalism, disturbing the peace, or other inappropriate

behavior as determined by the adult leadership in accordance with the youth leadership or Temple staff will not be

tolerated. I understand that I will have to pay for any damage that I cause. I understand that no gambling is

allowed except for fundraisers agreed upon by the adult leadership.

• I will not engage in any activities that can be deemed as hazing, sexually harassing, demeaning, or hurtful.

• I agree to refrain from inappropriate sexual behavior.

• I agree to abide by any additional rules, pertinent to a specific event, which may be announced, and to accept the

consequences of their violation.

By agreeing to these rules, I accept the following consequences. Anything undefined or unclear is up to the discretion

of the Temple Sole staff. I agree to these codes of conduct when I am attending any Temple organized event, URJ

event, or any NFTY event.

Consequences:

Offense: Immediate suspension from event plus suspension from the next event of that type of event. If the next

event is the elections event for that youth group, they are unable to run.

Offense: Same as first offense and cannot return until after a meeting with student, parent and staff.

Offense: Immediate suspension until professional help is received and return to events will be up to the discretion

of Temple Solel Staff.

For leadership position holders and/or Kavannah members:

Same as above plus a one-year suspension from leadership or running for board from time of infraction.

Student Signature: _____________________________________ Date: _____________________________

Parent Signature: ______________________________________ Date: _____________________________

Please check all that apply so that we can better serve your needs.

Interests

Basketball

Theater

Golf

Art

Tennis

Dance

Baseball

Music

Football

Plays an instrument

Soccer

Social action

Softball

Environment

Surfing

Hunger/homeless issues

Frisbee

Politics

Rollerblade/skate

Human rights

Skateboarding

Animal rights

Work with children/babysitting

Domestic abuse

Discussion groups

Computer interests

Meditation

Hiking

Leadership opportunities

Camping

Jewish philosophy

Rock Climbing

Judaica

Kayaking

Travel

Wakeboard

Israel

Other (please list)