Youth Group Application 2019-20

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We have an exciting year planned for our youth groups in 2019-20. Please fill out the information below to join our youth groups, grades K - 12.

Bonim (K - 2nd grade)
Machar (3rd - 5th grade)
Kadima (6th - 8th grade)
USY (9th - 12th grade)

If you have any questions, please contact the BSO office at 301.774.0879.

* Name of Parent completing form:

* Last Name of Parent completing form:

* Email Address

* Cell Phone

Child 1 Information

* First Name

* Last Name

* Date of Birth

* Grade

Child's Mobile Number

Child's Email Address

Youth Group Fee

This year Bonim and Machar registration fees include youth group membership and activity expenses. Kadima and USY registration fees cover membership only.

Child 2 Information

First Name

Last Name

Date of Birth

Grade

Child's Mobile Number

Child's Email Address

Youth Group Fee

This year Bonim and Machar registration fees include youth group membership and activity expenses. Kadima and USY registration fees cover membership only.

Child 3 Information

First Name

Last Name

Date of Birth

Grade

Child's Mobile Number

Child's Email Address

Youth Group Fee

This year Bonim and Machar registration fees include youth group membership and activity expenses. Kadima and USY registration fees cover membership only.

Total Youth Group Fee

* Home Address

* Home Phone Number

Guardian 1 Information

* Full Name

* Cell Phone

* Email

Guardian 2 Information

* Full Name

* Cell Phone

* Email

To Be Completed by a Parent/Guardian:

Does your child have any allergies or medical conditions that require special medication or attention?

List medication & dosages

Any other medical conditions we should be aware of?

List allergies

If parents are unable to be reached in an emergency, please contact the following:

* Full Name

* Relationship

* Phone

* Full Name

* Relationship

* Phone

Please provide the following insurance information:

* Guardian's Name

* Insurance Company Name

* Insurance ID #

* Insurance Company Address

* I would like to help chaperone an event in the month(s) of:

Permission/Release:

YesNo

I give B'nai Shalom of Olney (BSO) my permission to use pictures of my child at events for BSO publicity and communication. (If box is not checked 'YES', your child's picture will not be featured in any BSO publications.)

* Guardian's Signature

I give my child(ren) permission to attend and participate in B'nai Shalom of Olney's Youth Department activities. I hereby authorize the supervisory person present to grant approval for treatment in an emergency. BSO shall not be liable or responsible for any injury or loss suffered by or to any participant in this activity while the participant is attending or engaged in this activity or in transit to or from the activity, whether such injury or loss is caused by the negligence of any agent, employee or any other person acting on behalf of BSO.

* Today's Date

Wed, April 24 2024 16 Nisan 5784