Youth Group Membership Form 2022-2023

TEMPLE ADAT ELOHIM
2022-2023 YOUTH GROUP MEMBERSHIP FORM

MAETY
Mini Adat Elohim Temple Youth (4th & 5th Grade)

JAETY
Junior Adat Elohim Temple Youth (6th & 8th Grade)

AETY
Adat Elohim Temple Youth (9th-12th Grade)

4th through 12th grade students, as part of the Temple Adat Elohim Youth Group, will continue to build strong, vibrant Jewish identities, and life-long connections to each other, and our Temple, through unique and interesting social events and actively participating in Tikkun Olam, helping to heal our world.

There is a membership fee to help keep the youth program running. Payment will be due when you submit your form.*

Some partnership levels include Youth Group membership. Click here to find out which levels include youth group membership fees.

* Membership Form Confirmation Email Address

Student Information

* Student First Name

* Student Last Name

* Street Address

* City

* Zip

* Student Age

* Date of Birth

* Student Grade

* Student Email

Allergies (if applicable)

Parent Contact Information

* Parent 1 First Name

* Parent 1 Last Name

* Parent 1 Email

* Parent 1 Cell Phone

Parent 1 Work Phone

Additional Parent?

NoYes

Parent 2 First Name

Parent 2 Last Name

Parent 2 Email

Parent 2 Cell Phone

Parent 2 Work Phone

Student Emergency Contact Information

* Name of Emergency Contact (other than parents)

* Relationship to Student

* Emergency Contact Cell Phone

Emergency Contact Home Phone

Emergency Contact Work Phone

Student Physician Information

* Primary Physician's Name

* Primary Physician's Phone Number

* Primary Physician's Address

* Insurance Provider

* Group Policy Number

Medical and Liability Release

MEDICAL AND LIABILITY RELEASE: I hereby grant permission for my child to participate in all Temple Adat Elohim’s youth programs, activities and events and do release Temple Adat Elohim and its representatives from all liability arising out of my child’s participation in such activity. In addition, I, the undersigned parent/guardian of the above child, do further certify that my child is physically able to participate in such activity and hereby authorize Temple Adat Elohim and its authorized representatives as agents for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is to be rendered under the general or specific supervision of any licensed physician (under the provisions of the California Medicine Practice Act) or the staff of a licensed hospital, whether such diagnosis, examination or treatment is rendered at the office of the said physician, or at such hospital agree to pay all expenses incurred. It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of our above named agents to give specific consent to any and all such examinations, diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. The authorization is given pursuant to the provisions of section 25.8 of the Civil Code of California.

By entering your name in the box below you understand and agree to the medical and liability release statement.

Photo Release

PHOTO RELEASE: Throughout the year, Youth Group staff members and AETY Board members will be taking photographs/video of your children during events. These photographs/video may be used in publicity literature, such as brochures, newsletters, videos or posted on the TAE website. They may also be used on our Temple Facebook page and other forms of publicity (bulletin boards, presentations etc.)

By entering your name in the box below, you give permission for Temple Adat Elohim Youth Group to use your child’s picture in our promotional media and materials.

YOUTH GROUP POLICIES & CODE OF CONDUCT FORM

Membership dues are set each year. These dues go towards Youth Group on-site/off-site events and transportation, staffing, food, beverages and other supplies for said events.
2022-2023 Youth Group Membership fee is $36.00 for Temple Adat Elohim members. It will be $72.00 For non-temple members. These fees are separate from occasional individual event fees.
Membership fee is not pro-rated based on time of enrollment.
Certain Youth Group events will have an additional cost; however, being a Youth Group member will give you a discount for all events.

Waivers of liability:

Members: liability waivers will be on the back of the membership form for parents to sign at the time of enrollment.
Parents must sign the TAE liability waiver when enrolling their child in Youth Group. An additional event-by-event liability form may be necessary.
The TAE waiver will remain in effect for one year at the time it is signed.

Behavior/Alcohol/Drug Policy:

Members agree to interact with other Youth Group members in positive ways and avoid intentionally using language or behavior that is discriminatory, hurtful or dangerous.
Cigarette smoking is prohibited at all youth group events.
Possession and/or use of alcohol is prohibited at all youth group events.
Possession and/or use of any non-prescribed or ‘recreational’ drug or mind-altering substances are prohibited at all youth events.
Being under the influence of any of the above mentioned substances is prohibited at all youth group events.
Members agree to refrain from inappropriate sexual behavior.
Members understand there are no guests allowed at any event or program, unless permission is granted in advance by the advisor, and unauthorized guests will be asked to leave immediately.
Member will attend and participate fully in the entire event or program, unless members have permission from the advisor to do otherwise. Member will arrive on time and stay till the end, and remain on the premises at all times.
Members agree to abide by any additional rules, pertinent to a specific event, as specified by the advisor.

Violation of the Law:
Anything to be considered breaking the law such including, but not limited to: stealing, providing illegal substances to others, vandalism, physical harm to others will not be tolerated.

Consequences for Violation of Youth Policy:
Temple Adat Elohim is committed to helping our youth mature and become responsible young adults. We understand that children make mistakes in the process of growing and maturing. We want to enable them to recognize their behavior; learn from their mistakes and move forward in a more positive manner.

Consequences will be determined in consultation with Youth Advisor, Cantor, and the guardian/parents of the individual(s). These consequences will be at the discretion of said individuals and may result in a letter of apology, suspension, removal from the event and/or the youth group and other actions the Advisor and Cantor see fit. We reserve the right to expel any individual(s) from the program.

I have read the above rules, designed to promote the health and safety of all youth program participants, and have indicated my acceptance by my signature. I agree to adhere to these policies in order to make the Temple Adat Elohim Youth Group a positive, fun and safe place for all members.

CODE OF CONDUCT - STUDENT SIGNATURE: I have read the above rules, designed to promote the health and safety of all youth program participants, and have indicated my acceptance by entering my name below. I agree to adhere to these policies in order to make the Temple Adat Elohim Youth Group a positive, fun and safe place for all members.

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CODE OF CONDUCT - PARENT SIGNATURE: I have read the above rules, and have discussed them with my child. I indicate my agreement to this Code of Conduct by entering my name in the box below.

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Youth Group Membership Payment

Total

Fri, March 31 2023 9 Nisan 5783