USY Membership Application 2016-2017

Vancouver Nitzachon Chapter of USY

2016-2017 Membership Application
The United Synagogue Youth (USY) chapter at Congregation Beth Israel is known as Vancouver Nitzachon. USY is the official youth group of the Movement for Conservative Judaism, targeted at grades nine through twelve. Nitzachon aims to bring Jewish kids in the Vancouver area to meet each other, have fun, and grow in a Jewish environment.

Please send this form along with the $50 membership fee ($55 for non-BI members) to the youth office at Congregation Beth Israel. We will include you in our phone-outs, mailings and friend you on Facebook to ensure that you have every opportunity to become involved. Your membership will allow you to attend chapter events at reduced prices and will enable you to attend USY regional and international programs.
USYer's Information
USYer's Name: *

First Name Last Name
USYer's Birthdate: *

Month Day Year
Grade: *
USYer's Email *
USYer's Primary Phone: *

Area Code Phone Number
USYer's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Medical Information:

The information on this form will be kept strictly confidential. Each student/youth group member must have a medical history form on file with the Beth Israel School and Youth Office. Once a form is on file, it is valid for 12 months. It is your responsibility to advise the office of any changes to the information below.
Child’s Health History (check where applicable and please note approximate dates and write "N/A" where non-applicable):
Asthma *
Bleeding/clotting disorders *
Chicken Pox *
Convulsions *
Counseling *
Diabetes *
Frequent ear infections *
German Measles *
Hay Fever *
Heart Defect or disease *
Hypertension *
Measles *
Mononucleosis *
Mumps *
Operations or serious injuires: *
List any other medical problems or conditions that we should be aware of, including disabilities, chronic or recurring illnesses, recommendations or restrictions, allergies (to foods, drugs, plants, insects, etc). Include any current medications: *
Year of last tetanus booster shot: *
Medical Insurance Information:
BC Care Card Number: *
Name of Family Doctor: *

First Name Last Name
Doctor's Phone Number: *

Area Code Phone Number

Consent:
ALL THE INFORMATION PROVIDED IN THIS FORM IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THE IMPORTANCE OF KEEPING THIS FORM CURRENT AND ACCURATE. I ALSO CERTIFY THAT MY CHILD’S IMMUNIZATION STATUS IS UP TO DATE.
Parent's Initials: *
Parent/Legal Guardian; Please read the following and initial below:

I/we understand that if my/our child is present at any Nitzachon event, that he/she is attending with my/our consent and permission. I/we hereby give permission to Beth Israel Youth Department and its employees and agents to take my child on field trips, programs, and events that may take place in the United States, and do hereby release its agents, officers, and employees from any and all liability arising from my child’s participation. In case of accident/illness, Beth Israel representatives have my permission to obtain proper aid (hospitalization, x-ray, etc.) deemed necessary by a doctor and I/we agree to pay all expenses incurred. Every attempt will be made to reach the child’s parent/legal guardian and/or doctor for any emergency arising.
Parent's Initials: *
Membership Fees:
Please choose one of the following: *
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BI Member - USY Membership Fee $ 50.00 CAD

Non BI Member - USY Membership Fee $ 55.00 CAD
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Vancouver Nitzachon Chapter of USY