JOIN CBI KADIMA COMPLETE FORM & MAIL WITH DUES CHECK

Scotch Plain Ka!i"a M#"$#%hi&

A&&lication '()*+'(),
Name: ___________________________________ Hebrew Name:_____________________________
Birthday:____________________________________________________________________________
Address: ____________________________________________________________________________
City and Zip: _________________________________________________________________________
Home Phone Number: _______________________________
Youth's Email Address: ________________________________________________________________
Youth's Cell (i appli!able": ___________________________
#!hool: _____________________________________________________________________________
Current $rade: ______
%other&s Name: ________________________ %other&s Cell: _______________________
%other&s Email: ______________________________________________________________________
'ather&s Name(Hebrew Name: ______________________ 'ather&s Cell:
________________________
'ather&s Email: _______________________________________________________________________
Are you a CB) member* ______ Yes _______ No
) not+ is your amily a,liated with a syna-o-ue* ) so+ whi!h one* ______________________
E.ents ) would li/e to ha.e this year:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________
01E#:
1#Y (Che!/ payable to 2CB)3": 456 or CB) members
466 or non7CB) members
Please 8ll out orm !ompletely and mail it alon- with the atta!hed medi!al release to:
0ana 9a.(:adima
Con-re-ation Beth )srael
;< #halom =ay+ #!ot!h Plains+ N> ?@?@A
Buestions*
'or Cuestions+ please !onta!t 0ana 9a. at !biyouth;<D-mailE!om
ALL -OUTH .ROUP MEMBERS MUST PRO/IDE MEDICAL AND EMER.ENC- INFORMATION ON
RE/ERSE SIDE0
For USY & Kadima only: PLEASE READ AND SIGN THIS CODE OF CONDUCT
In connection with any chapter/regional program (including dances), including travel to and from such program:
1. There is to be no smoking.
2. There is to be no possession or use of any narcotics, mariuana, other illegal drugs or prescription drugs not prescribed for
the user.
!. There will be no possession or consumption of any alcoholic beverages.
". There will be no shoplifting or any other theft of any kind.
#. If a youth group member is caught in possession of/or using alcohol or illegal drugs, he/she will immediately be sent home at
his/her parents$ e%pense.
&. 'll convention delegates are e%pected to be in sessions (services, meals, study groups, etc.)
(. 'll males are e%pected to bring a tallit and tefillin to conventions.
). *ach participant is e%pected to maintain proper decorum and attitude during the entire program. +isruptive behavior
(including, among other things, inappropriate se%ual behavior) will not be tolerated. ,our parents will be responsible to pay for
any damage you may cause.
-. .o attendee may leave the facility e%cept at those times specified by the schedule.
/0. 1roper dress is e%pected of everyone. 2or 3habbat, males must wear a acket and tie or sweater, no eans or sneakers.
2emales are to wear dresses or skirts, no shorts, culottes, or dress pants.
//. .o attendees may leave the synagogue e%cept at those times specified by the convention schedule. 'll attendees must be in
their assigned houses at curfew and remain there.
/4. *ach participant is e%pected to conduct him/herself appropriately as a 5onservative 6ew (including through the observance of
3habbat and 7ashrut), in accordance with applicable standards of the 8aw and 3tandards 5ommittee of the 9abbinical
'ssembly and/or the local 9abbinical 'uthority.

:3, or 7adima +irector, in consultation with the 9egional ,outh 5ommission, reserves the right to enforce other rules relating to the
integrity of the 9egional ,outh 1rogram and/or the health, safety, or welfare of its participants.
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. 'ny violation of this code of conduct may result in the participant being
sent home at his/her parents; e%pense. The 9egional +irector has the sole discretion to send a participant home.

3I<.'T:9* =2 1'9*.T 3I<.'T:9* =2 7'+I>'/:3, >*>?*9
MEDICAL INSURANCE CO POLICY NUM!ER
ALL KADIMA/USY MEMBERS MUST BE COVERED BY HEALTH CARE INSURANCE IN ORDER TO PARTICIPATE IN REGIONAL PROGRAMS.
*>*9<*.5, 5=.T'5T 1*93=. *>*9<*.5, 1@=.* A
(.ot a parent)
5urrent >edication(s) or >edical Treatment
Bill your child have medication with them for the weekendC D , D .
@as your child been diagnosed with '+@+/'++C , . If yes, is your child currently on medicationC
+oes your child have any allergiesCDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
9ecent illness, hospitaliEation, inury or surgery
+isability, chronic illness or condition
'ctivity restriction or modification
STATEMENT AND EMERGENCY AUTHORI"ATION
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 e%cept as noted under
9estrictions or >odifications above.
In case of a medical emergency, accident, or health problem where immediate treatment is deemed necessary, every effort will be
made to e%peditiously contact the parent(s) or guardian(s) of the participant, or the emergency contact person listed above. In the event
I cannot be reached, I hereby give permission to the physician selected by the 9egional :3,/7adima +irector, 5hapter 5haperone, or
his/her designee, to hospitaliEe, secure proper and ongoing treatment, and to order inection, anesthesia, or surgery for my child as
named above. I am aware that this form may be photocopied for use by medical caregivers.
This release will remain in effect for the 2014-2015 KADIMA/USY season from !ate si"ne! #ntil 0$/%0/15& I will notif' the a!(isor if there is an'
chan"e in m' chil!)s ins#rance information&
SIGNATURE OF PARENT OR LEGAL GUARDIAN
PRINT NAME: DATE: