Youth Group Membership Form 25/26

CBI Youth Dept Membership Form 2025-2026

Membership forms and dues are good for one school year lasting from July 1st to June 30th. Forms must be updated each year and dues paid for each year. Please complete a separate form for each participant.

If you have any trouble accessing the form or questions, email youth@cbi18.org.

It is expected that you and your child (the "we" in the form) will go over the Release & Authorization and Code of Conduct together and your child will abide by this policy. As a parent, please initial as you go through the forms (the "I" in the form). There is space for the participant to sign at the bottom of the form. It is recommended both parents (if applicable) familiarize themselves with the rules, even though only one is required to initial and sign.

Are you current members of Congregation B'nai Israel? If not, where are you affiliated?

* Parent/Guardian 1 First Name

* Parent/Guardian 1 Last Name

* Parent/Guardian 1 Cell Number

* Parent/Guardian 1 Email

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Cell Number

Parent/Guardian 2 Email

Youth First Name

Youth Last Name

Youth Email (If they have one)

Youth Phone (if they have one)

Youth Address

Youth City

Youth State

Youth Zip

Youth Date Of Birth

Youth Gender

Grade in Sept 2025

Youth Allergies

Please indicate if life threatening allergy, mild allergy, sensitivity, or other.

Other Medical Conditions

Medications

Youth Medical/Health Insurance Company Name

Medical/Health Insurance Policy #

Medical/Health Insurance Group #

Primary Physician Name

Primary Physician Phone Number

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Cell Number

Emergency Contact Email

Emergency Contact Relationship to Youth

Youth Group Release & Authorization

We understand that Congregation B'nai Israel (CBI) Youth Group (CBIYG) will enforce a behavior management policy known as the Code of Conduct. We understand that serious infractions, including but not limited to stealing, fighting, possession of contraband on campus (weapons, drugs, or alcohol), willful destruction of property, bullying (including written, verbal, and/or online), and/or sexual harassment will result in an immediate removal from programs and may result in discipline up to and including suspension from future programs or dismissal with no refund of payment. We have read, understand and agree to be bound by this enrollment agreement for myself and on behalf of my child. Please initial below to confirm that you have read and agree with this statement.

Please initial above to confirm that you have read and agree with this statement.

We understand that Congregation B'nai Israel (CBI) Youth Group (CBIYG) will enforce a behavior management policy known I give my child my full consent and permission to participate in all manner of activities offered by CBIYG to its participants. I agree that neither CBI nor CBIYG shall be held liable for accident or injury that my child may sustain in connection with any such activity. I agree to fully release and hold harmless CBI and CBIYG (including their agents, employees, and officers) from any claims, damages, and/or liabilities arising from any accident or injury to or by participant. This includes expenses and costs for medical care and services that a participant may receive due to any injury or illness suffered while attending or participating in a CBIYG event.

Please initial above to confirm that you have read and agree with this statement.

We understand that Congregation B'nai Israel (CBI) Youth Group (CBIYG) will enforce a behavior management policy known I give my child my full consent and permission to participate in alI give permission for CBIYG to request and maintain a record of my child’s medical information, including but not limited to allergies, medical conditions, and insurance information, for use in case of emergency.

Please initial above to confirm that you have read and agree with this statement.

I agree that CBI and CBIYG are authorized to use participant's photographs, images, recordings, videos, likeness, achievements, and artwork in promotional publications, including on the synagogue's website and in print materials for community outreach.

Yes, we have read and agree.No, I do not wish my child’s image, likeness, etc. to be used.

I give permission for my child to ride in a properly insured vehicle driven by a licensed adult (over the age of 18) driver.

Yes, we have read and agree

It is CBIYG policy to use licensed adult drivers whenever possible. With full understanding of this policy and the risks involved, if there is a shortage of licensed adult drivers, do you give consent for your child to ride with a licensed driver under the age of 18?

Yes, I DO give my child consent to ride with a licensed driver under the age of 18.No, I DO NOT give my child consent to ride with a licensed driver under the age of 18.

If there is a shortage of licensed adult drivers do you give permission for your USYer, who does have a valid driver's license (not provisional), to drive other USYers during an event.

Yes, I do give my USYer permission to drive others. I affirm that the participant’s vehicle is in good working order and my USYer is covered under an insurance plan. My child has had a drivers’ license for a full year.No, I do not give my USYer permission to drive others.Not applicable to my child.Please note: your USYer's vehicle must in good working order and your USYer must be covered under an insurance plan. Your teen must have had their drivers’ license for a full year and be able to safely/legally drive other passengers.

I affirm that the information on this form and the membership form is accurate, complete, and inclusive to the best of my knowledge. I understand the importance of keeping this information accurate, and I agree to contact the CBI Youth Director prior to any program that my child will attend if there is any kind of change to any of the information provided.

Yes, I have read and agree.

Code of Conduct

1. There is to be no smoking or vaping. There is to be no possession of cigarettes, e-cigarettes or any associated liquid or paraphernalia.

2. There is to be no possession or use of any narcotics, marijuana, illegal drugs, or prescription drugs not prescribed for the user; drug paraphernalia; matches; firecrackers (or similar devices); knives or any other sharp or dangerous objects.

3. There will be no possession or consumption of any alcoholic beverages.

4. There will be no shoplifting or theft of any kind.

5. If a participant is caught in violation of any of the above statements, the participant will immediately be sent home at parents’ expense. Furthermore, CBIYG reserves the right to impose additional sanctions in connection with this or any other improper behavior as it sees fit.

6. For overnight events, at no time are males permitted in sleeping rooms or on floors occupied by females, and at no time are females permitted in sleeping rooms or on floors occupied by males.

7. Each participant is expected to maintain proper decorum and attitude during the entire program.

8. Disruptive behavior (including but not limited to inappropriate sexual behavior) will not be tolerated. Any inappropriate messages or content shared by anyone in any manner during an event will be considered a violation of the code of conduct.

9. No participant may leave an event early without the express permission of the CBI Youth Director or other designated staff member. At overnight events, participants must be at all scheduled programs and, during specified free time, remain within boundaries set forth by the CBI Youth Director or other designated staff member.

10. During events, each participant is expected to maintain appropriate conduct as a Conservative Jew (including observance of Shabbat and kashrut).

11. Participant is expected to dress appropriately. Clothing on which profanity or inappropriate language, pictures, or symbols are written, printed, or depicted is prohibited. Clothing should not be made of see-through material, and undergarments should not be visible. Clothing, including bathing suits, should be of an appropriate length such that a person’s private areas are adequately covered and not accentuated.

12. To celebrate and mark the important distinction between Shabbat and the rest of the week, appropriate Shabbat attire is required on Shabbat. Each participant is expected and encouraged to bring and use a head covering at appropriate times, and tallit and tefillin at Shacharit (morning) services. For participants not yet of b’nai mitzvah age, only head coverings are expected. The CBI Youth Director or other designated staff member responsible for the program may determine that because of weather, location of event, or nature of the activity, variations or exceptions may be permitted or necessary.

13. The CBI Youth Director or other designated staff member, in consultation with the CBI Youth Vice Presidents, reserves the right to search the room and belongings of any attendee if reasonable grounds exist to believe that such a search is necessary to secure the health, safety and/or welfare of the program and/or its participants. USY also reserves the right to enforce other rules relating to the integrity of the program and/or the safety, health or welfare of its participants.

14. CBIYG has a zero-tolerance policy regarding any bullying, hazing, or harassment. This includes cyberbullying--that is, bullying that occurs using the internet, a mobile phone, or other technology to engage in any of the following inappropriate misconduct: posting nasty or threatening comments on someone’s social networking profile; sending anonymous text or picture messages to intimidate or embarrass; hacking existing website accounts or creating fake profiles of people to intimidate or embarrass; scaring or embarrassing others; or spreading rumors or trying to isolate others using technology. The above list is not inclusive. Any individual involved in these or similar acts will be subject to disciplinary action, up to and including removal from our programs.

15. By my signature, I certify that I have read the Convention Code of Conduct (above). I will adhere to the program, observe the above Code of Conduct, I will conduct myself in a manner reflecting credit upon my chapter, congregation, and community.

Participant Signature (Please type name)

Parent Signature (Please type name)

* (Non-CBI member) USY Membership Fee

Total

Wed, September 3 2025 10 Elul 5785

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