Kettler and Levy Families Youth Connection Registration Form

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* Participant First Name

* Participant Last Name

Gender

Birthday (MM/DD/YYYY):

Grade (2024/2025)

* Address

* City

* State

* Zip

* Participant Home Phone Number

* Participant Cell Phone Number

Participant Email

* T-Shirt Size

* Parent's Name

Parent's Cell Phone Number

* Parent Email

Emergency Contact

Emergency Contact Phone Number

Are you a Beth Torah Member?

Are you a member of another synanogue?

If yes, where?

Was your child born Jewish?

If no, please explain

Has your child attended another Jewish education program?

If yes, where?

Medical Insurance Company

Medical Insurance Company Phone Number

Medical Insuracne Policy Number

Name of Insured

Physician's Name

Physician's Number

Does your child have any allergies?

Is your child on any medications?

Please include any immportant information about your child

Tuition

Group/Grade	Member Fees	Non-Member Fees
Chalutzim (K - 5th Grades)	$125	$150
Kadima (6th to 8th Grades)	$125	$150
USY (9th to 12th Grades)	$150	$175

Membership Tuition

Chalutzim (K to 5th grades) - BTBRC MEMBERChalutzim (K to 5th grades) - BTBRC NON MEMBERKADIMA J2M (select this option if your child is currently enrolled in J2M)KADIMA (select this option if you had a Bar/Bat Mitzvah last year)KADIMA - BTBRC MemberKADIMA - NON MEMBERUSY (9th to 12th grades) & Kadima (6th to 8th grades) - BTBRC MEMBERUSY (9th to 12th grades) & Kadima (6th to 8th grades) - BTBRC NON MEMBER

Total

Beth Torah Benny Rok Campus’ Kettler and Levy Families Youth Connection programs may be photographed from time to time by our staff and media. Possible uses for these photos can include, but are not limited to: projects, publication in editorial and promotional print materials, publication on Beth Torah Benny Rok Campus’ web site, and publication in newspapers, magazines, and other materials. By signing below, you agree that Beth Torah, its agents or assignees, and media outlets may use these photos, and that neither your child, nor you or your agents or assignees, will be entitled to any compensation for such uses.

I agree to the above and am registering my child for the Kettler and Levy Families Youth Connection and give permission for them to participate in all Kettler and Levy Families Youth Connection events.

Code of Conduct

I have read the rules below, designed to promote the health and safety of all students and to protect the property of our students, our building, and any building or property in which we conduct programs. I have indicated my unqualified acceptance by my signature and that of my parent / guardian. I understand that appropriate consequences will result from violating this Code of Conduct:

I will attend and participate fully in the entire program, unless otherwise agreed upon by the Youth Director. I will arrive on time, stay until the end, and remain in the program, and on the premises at all times.
I understand that vandalism, disturbing the peace, or other inappropriate behavior, as determined by any teacher or member of the administrative staff, will not be tolerated. I understand that I will have to pay for any damage that I cause. I further understand that any such vandalism or inappropriate behavior could result in my suspension or expulsion.
I understand that visitors must be approved in writing by the Youth Director in advance of the visit.
I agree to abide by any additional rules which may be determined by my teacher, or any member of the Beth Torah faculty or administration, which may be announced, and to accept the consequences of the violation of any rules. I understand that I represent myself, my family, and Beth Torah at all times.

I understand that if my child violates any of the rules stated above, I will be responsible for paying for any damage and will have to pick up my child from the program immediately. I further understand that any such vandalism or inappropriate behavior will result in my child's possible suspension or expulsion.

Trip Release

I give permission for my son/daughter to participate as a member of the Beth Torah Education/Youth Department in all programs including off-campus trips, including movies that are rated PG13. In the event of an emergency, surgical or otherwise, and I can't be reached, I hereby give permission for my child to be transported to the nearest medical facility and specifically authorize either the representative of Beth Torah or my emergency contact to select a physician and or authorize medical treatment including hospitalization, anesthesia, injection, surgery or other measures which he/she feels are in the best interest of my child. Further, I accept full responsibility for payment of any such services rendered. This release applies to all Beth Torah school and youth programs which my child participates and/or attends.

* Parent's Signature

Participant Signature

Thu, April 3 2025 5 Nisan 5785

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Kettler and Levy Families Youth Connection Registration Form

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