TO BECOME A SJCUSY MEMEBER, JUST PRINT OUT THE APPLICATION, FILL IT OUT, AND BRING IT TO YOUR NEXT EVENT WITH THE MONEY ENCLOSED! :)
San Jose City U.S.Y.
Application for Membership 2005-2006
CHILDREN’S INFORMATION PARENTS’ INFORMATION
CHILDREN'S INFORMATION PARENT'S INFORMATION
NAME NAME(S)
_______________________
ADDRESS
_____________________________ HEBREW NAMES
MOTHER_____________________
FATHER______________________
PHONE ___________________ PHONE______________________
EMAIL ___________________ EMAIL ______________________
GRADE __________ (9-12)
SCHOOL ATTENDING _________________________
DATE OF BIRTH __________________
TEMPLE AFFILIATION ________________________
Dues*: Cost
Cost: $30
Amount Enclosed: $ ________________
Please send your completed application (both sides) and check made payable to San Jose City USY:
Congregation Sinai USY
1532 Willow Brae Avenue
San Jose, CA 95125
Call or email Jake, USY Advisor with questions-408-726-3055 or Jorrin@ix.netcom
In connection with any SJCUSY program, including travel to and from such program:
1. There is to be no smoking.
2. There is to be no possession or use of any narcotics, marijuana, other illegal drugs or prescription drugs not prescribed for the user.
3. There will be no possession or consumption of any alcoholic beverages.
4. There will be no shoplifting or any other theft of any kind.
5. If a USYer is caught in possession of/or using alcohol or illegal drugs, he/she will immediately be sent home at his/her parents’ expense, if done a second time he/she will be on probation from future events.
6. No buying or bringing non kosher foods at an event.
7. Each participant is expected to maintain proper decorum and attitude during the entire program. Disruptive behavior (including, among other things, inappropriate sexual behavior) will not be tolerated. Your parents will be responsible to pay for any damage you may cause.
I have read these rules and understand them fully. I certify that I will adhere to this Code and will conduct myself in a manner reflecting credit upon myself, my chapter, congregation and community. Any violation of this code of conduct may result in the participant being sent home at his/her parents' expense. The Advisor has the sole discretion to send a participant home.
SIGNATURE OF USYer
I , the parent/guardian of , a minor, who will be participating in
The SJCUSY chapter, for the year 2005-2006, do hereby certify that I have read the Code of Conduct set forth above. I do hereby agree that if my child who has signed the above Rules of Conduct fails to adhere to the Code, then in such event those persons in charge of the program may send my child home at my expense. I understand that the Advisor has the sole discretion to send my child home. I have been made aware of the fact that the events in which my child is participating may be photographed by either amateur or professional photographers, that the photographs taken may be used both for purposes of reporting on the event or for such other use as the SJCUSY website. I have no objection to the pictures taken being used at any time for promotional use. It is my understanding that by signing this document I consent to the use of the pictures just referred to for any purpose whatsoever.
SIGNATURE OF PARENT DATE
INSURANCE CO. POLICY NUMBER
EMERGENCY CONTACT PERSON
EMERGENCY PHONE # (not a parent)
Please provide details for applicable items pertaining to your child.
Allergies (Food, drug, insect or substance)
Current Medication(s) or Medical Treatment
Recent illness, injury or surgery, disability, chronic illness or condition
Activity restriction or modification
STATEMENT AND EMERGENCY AUTHORIZATION
I, the parent or legal guardian, of the applicant state that he/she is in good/normal health, has no physical or mental handicaps that would interfere with full participation in the program, and has my permission to engage in all available activities except as noted under Restrictions or Modifications above. In case of a medical emergency, accident or health problem where immediate treatment is deemed necessary, every effort will be made to expeditiously contact the parent(s) or guardian(s) of the participant, or the emergency contact person list ed above. In the event I cannot be reached, I hereby give permission to the physician selected by the Regional USY/Kadima Director, or his/her designee, to hospitalize, secure proper and ongoing treatment and to order injection, anesthesia, or surgery for my child as named above. I am aware that this form may be photocopied for use by medical caregivers.
SIGNATURE OF PARENT OR LEGAL GUARDIAN
PRINT NAME: DATE: