CBA Youth Department Registration 5785

Please note: If you are registering for JLC or Sabra, your Youth Department Membership is included.

From kindergarten through high school, our award-winning Youth Department is home to an active and diverse youth community. Guided by a professional staff, our children and teenagers’ grades K-12 are engaged in social, educational, religious, and social action programming. Join us for another exciting year of grade specific out of the classroom activities.

Parent Information

* Parent 1 First Name

* Parent 1 Last Name

* Parent 1 Email

* Parent 1 Phone

Parent 2 First Name

Parent 2 Last Name

Parent 2 Email

Parent 2 Phone

* Youth Home Address

* City

* State

* Zip

* Are the parents divorced/seperated?

please provide the address of the 2nd household

* Which home is the main home for the child?

Only answer if you check the box "Divorced"

2nd Home Address

City

State

Zip

Emergency Contact (Other Than Parent)

* Name of Emergency Contact #1

* Relationship

i.e. grandparent, family friend, etc...

* Mobile

best number to be reached

* Name of Emergency Contact #2

* Relationship

i.e. grandparent, family friend, etc...

* Mobile

best number to be reached

Medical Information

Our policy is that all participants in youth programs require proof of Medical Insurance coverage, including company name, policy number, etc.

* Name of the Primary Insured

* Medical Insurance Company

* Policy / Group #

* Certificate # (or group coverage)

* Insurance Company's Phone Number

* Name of Primary Physician

* Phone Number of Primary Physician

Youth Information

* How many youths will you be registering?

Youth #1

* First Name

* Last Name

* Birth Date

* Choose the program your youth is entering:

* Youth's Email

if applicable

* Youth's Mobile

if applicable

* Name of secular school

* Grade in secular school

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

List all allergies to food, medications, plants, insects, animals, etc:

if none, please type n/a
If your child has an allergy to something that was not listed above, we are not responsible for any allergic reactions.

* I confirm that all my child/teen's immunizations, as required for public schools, are up-to-date.

If your youth is exempted from getting their immunization shots, we require that you to go through the California Immunization Registry - Medical Exemption (CAIR-ME), and fill out their form then bring us a printed validated form or email to cbayouth@betham.com.

* Please describe any physical, emotional, behavioral, or learning needs your child may have, so we are better able to provide them with appropriate programming and accommodations if necessary:

if none, please type n/a

* Does your child have an IEP or 504 Plan from your school district?:

Other: Please describe below if there is any other information you feel is important for us to know

Youth #2

* First Name

* Last Name

* Birth Date

* Choose the program your youth is entering:

* Youth's Email

if applicable

* Youth's Mobile

if applicable

* Name of secular school

* Grade in secular school

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

List all allergies to food, medications, plants, insects, animals, etc:

if none, please type n/a
If your child has an allergy to something that was not listed above, we are not responsible for any allergic reactions.

* I confirm that all my child/teen's immunizations, as required for public schools, are up-to-date.

* Please describe any physical, emotional, behavioral, or learning needs your child may have, so we are better able to provide them with appropriate programming and accommodations if necessary:

if none, please type n/a

* Does your child have an IEP or 504 Plan from your school district?:

Other: Please describe below if there is any other information you feel is important for us to know

Youth #3

* First Name

* Last Name

* Birth Date

* Choose the program your youth is entering:

* Youth's Email

if applicable

* Youth's Mobile

if applicable

* Name of secular school

* Grade in secular school

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

List all allergies to food, medications, plants, insects, animals, etc:

if none, please type n/a
If your child has an allergy to something that was not listed above, we are not responsible for any allergic reactions.

* I confirm that all my child/teen's immunizations, as required for public schools, are up-to-date.

* Please describe any physical, emotional, behavioral, or learning needs your child may have, so we are better able to provide them with appropriate programming and accommodations if necessary:

if none, please type n/a

* Does your child have an IEP or 504 Plan from your school district?:

Other: Please describe below if there is any other information you feel is important for us to know

Youth #4

* First Name

* Last Name

* Birth Date

* Choose the program your youth is entering:

* Youth's Email

if applicable

* Youth's Mobile

if applicable

* Name of secular school

* Grade in secular school

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

List all allergies to food, medications, plants, insects, animals, etc:

if none, please type n/a
If your child has an allergy to something that was not listed above, we are not responsible for any allergic reactions.

* I confirm that all my child/teen's immunizations, as required for public schools, are up-to-date.

* Please describe any physical, emotional, behavioral, or learning needs your child may have, so we are better able to provide them with appropriate programming and accommodations if necessary:

if none, please type n/a

* Does your child have an IEP or 504 Plan from your school district?:

Other: Please describe below if there is any other information you feel is important for us to know

Release Forms

No youth will be permitted to participate in Beth Am Youth events without this form completed.

PARTICIPATION PERMISSION AND RELEASE. I give my permission for my youth to attend all scheduled activities with Congregation Beth Am programs. I certify that my youth is (are) physically able to participate in Congregation Beth Am programs and release Congregation Beth Am and its representatives from any and all liabilities whatsoever which may arise from their participation in the programs of Congregation Beth Am. I understand that Congregation Beth Am will provide adequate supervision for all programs and will make every reasonable effort to ensure the safety of all participants. However, I am aware that as a non-profit organization, Congregation Beth Am cannot, and will not, assume responsibility for any accidents or loss of personal effects or loss of life at any event. I hereby release Congregation Beth Am from any liability whatsoever which may arise as a result of transportation to and/or from events, for any injury to my child during a program, and waive any claim that hereafter may arise, specifically agree not to sue or bring action against Congregation Beth Am or its representatives. I also agree to release and forever discharge Beth Am from any and all actions, suits, of any kind or nature, whether known or unknown, both in law and in equity, arising out of each scheduled activity my youth elect(s) to participate in. I hereby acknowledge and agree this release applies to any and all actions, suits, or claims, whether known or unknown, foreseen or unforeseen, patent or latent, arising out of each activity my youth elect(s) to participate in.

* Participation Permission & Release

YesNo

MEDICAL RELEASE. I consent and give permission for my youth to attend and participate in all activities arranged by Beth Am for which they are registered. I certify that my youth is/are physically and psychologically able to participate in all such activities. In case of emergency, I authorize Beth Am and its representatives, as my agent and at my sole cost and expense, to engage appropriate healthcare providers to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization, or medical procedures and services deemed appropriate under the circumstances if Beth Am is not able to contact me for instructions in a timely manner. I hereby authorize any hospital which has provided treatment to my youth pursuant to the provisions of Section 6910, of the Family Code of California to surrender physical custody of such youth upon the completion of treatment. This authorization is given pursuant to the Section 1283 of the Health and Safety Code of California.

* Medical Release

YesNo

YOUTH BEHAVIOUR. I understand that my youth will observe all the rules and regulations as stated by the Director of Youth Activities of Congregation Beth Am and their authorized representatives and that failure to comply will serve as a basis for suspension from participation without refund.

* Youth Behaviour

YesNo

PARENT CUSTODY AUTHORIZATION. I understand that my youth may be released to either of their parents or guardians unless Beth Am is is otherwise notified in advance, in writing, with proper documentation. Beth Am cannot withhold a youth from a parent unless this procedure is followed. In cases of custody issues, please obtain a Parent Custody Authorization Form from the office.

* Parent Custody Authorization

YesNo

PHOTO RELEASE. I give permission for my youth’s photo/video/written work to be used for press releases or other promotional literature

INFORMATION RELEASE. I give permission for my name/address/phone number to be given out to classmates for carpool information or social events/gatherings/class roster

Parent Information

Medical Information

Youth Information

Youth #1

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

Youth #2

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

Youth #3

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

Youth #4

HEALTH INFORMATION: If any of the below medical information changes, please notify us immediately

Release Forms

TOTAL PAYMENT DUE

Congregation Beth Am | 5050 Del Mar Heights Road | San Diego, CA 92130
858.481.8454 | welcome@betham.com