South Orange Kadima Membership

South Orange Kadima Membership

The South Orange Kadima Chapter is a joint Chapter with Congregation Beth El and Oheb Shalom Congregation

(6th and 7th Grade Application )

Name______HebrewName______

Address______

streettownzipcode

Homephonenumber______Kadimanik’scellphone______

Kadimanik’s E-MailAddress______

GradeasofSept2014:______Birthdate:______

BestwaytoreachKadimanik (circle one)

homephonecellphonetextmessagee-mail

Parentname(s)______

Parente-MailAddress(es)______

Parentcellphone(s)______

Bestwaytoreachparent(s)(circle1)

homephonecellphonetextmessagee-mail

Membership Fee:

__$40___BethElor___OhebShalommember(pleasecheckwhichone)

__$60Memberofanothercongregation(Cong.name)______

Pleaseprovidecopyofinvoiceshowingpaidmembershipwiththisapplication

__$60notaffiliatedwithasynagogue

Checksshouldbepayableto:

“Congregation Beth El”andmailed(ordroppedoffatthesynagogue)

CongregationBethEl

222IrvingtonAve

SouthOrange,NJ07079

Please be sure to fill out both sides of this form completely. Chapter membership eligibility is determined by the sponsoring synagogues. Themedicalreleaseon

thebackofthisformmustbefilledoutinordertoattend chapter and regional events.Ifyouhaveanyquestions,pleasecontact: Jamie Mittleman, Youth

ATTNPARENTS:Pleasekeepinmindthatyouarefillingoutthisinformationintheeventyourchildmustbetakentoamedicalfacilityintheeventofanemergency.Allattemptswillbemadetocontactyou,howeverthatmaynotbepossible. Please insure that all medical forms, medications, and allergies are completed in full.

PLEASEREADANDSIGNTHISCODEOFCONDUCT

Inconnectionwithanychapter/regionalprogram(includingdances),including traveltoandfromsuchprogram:

1.Thereistobenosmoking.

2.Thereistobenopossessionoruseofanynarcotics,marijuana,otherillegaldrugsorprescriptiondrugsnotprescribedfortheuser.

3.Therewillbenopossessionorconsumptionofanyalcoholicbeverages.

4.Therewillbenoshopliftingoranyothertheftofanykind.

5.IfaUSYmemberiscaughtinpossessionof/orusingalcoholorillegaldrugs,he/shewillimmediatelybesenthomeathis/herparents’expense.Furthermore,USYInternationalpolicystates:“AnyoneviolatinganysuchrulesataregionaleventfortheinfractionoftheserulesisbarredfromInternationaleventsforoneyearfollowingtheinfraction.Theseeventsinclude(butarenotlimitedto)theInternationalUSYConventionandUSYsummerprograms.”TheRegion reserves the right to impose additional sanctions in connection with thisoranyotherimproperbehavior asitseesfit.

6.AllConventiondelegatesareexpectedtobeinsessions(services,meals, studygroups,etc.)

7.Allmalesareexpectedtobringatallitandtefillin.

8.Eachparticipantisexpectedtomaintainproperdecorumandattitudeduringtheentireprogram.Disruptivebehavior(including,amongotherthings,inappropriatesexualbehavior)willnotbetolerated.Yourparentswillberesponsibletopayforanydamageyoumaycause.

9.Noattendeemayleavethefacilityexceptatthosetimesspecifiedbythe

schedule.

10.Properdressisexpectedofeveryone.ForShabbat,malesmustwearajacketandtieorsweater,nojeansorsneakers.Femalesaretoweardressesorskirts,noshorts,culottesordresspants.

11.Noattendeesmayleavethesynagogueexceptatthosetimesspecifiedbytheconventionschedule.AllUSY/KadimaMembersmustbeintheirassignedhousesatcurfewandremainthere.

12.Eachparticipantisexpectedtoconducthim/herselfappropriatelyasaConservativeJew(includingthroughtheobservanceofShabbatandKashrut),inaccordancewithapplicablestandardsoftheLawandStandardsCommitteeof theRabbinicalAssemblyand/orthelocalRabbinicalAuthority.

USYorKadimaDirector,inconsultationwiththeRegionalYouthCommission,reservestherighttoenforceotherrulesrelatingto the integrity of the Regional YouthProgramand/orthehealth,safetyorwelfareofit’sparticipants.

Ihavereadtheserulesandunderstandthemfully.IcertifythatIwilladheretothisCodeandwillconductmyselfinamannerreflectingcredituponmyself,mychapter,congregation,andcommunity.Anyviolationofthiscodeofconductmayresultintheparticipantbeingsenthomeathis/herparents'expense.TheRegionalDirectorhasthesolediscretiontosendaparticipanthome.

SIGNATUREOFPARENTSIGNATUREOFKADIMANIK

MEDICALINSURANCECO.

POLICYNUMBER

ALLKadimaMEMBERSMUSTBECOVEREDBYHEALTHCARE

INSURANCEINORDERTOPARTICIPATEINREGIONALPROGRAMS.

EMERGENCYCONTACTPERSON

EMERGENCYPHONE#

(notaparent)

CurrentMedication(s)orMedicalTreatment

Willyourchildhavemedicationwiththemfortheweekend?Y___N

HasyourchildbeendiagnosedwithADHD/ADD?____Y_____NIfyes,is

yourchildcurrentlyonmedication?

Doesyourchildhaveanyallergies?______

Recentillness,hospitalization,injuryorsurgery

Disability,chronicillnessorcondition

Activityrestrictionormodification

STATEMENTANDEMERGENCYAUTHORIZATION

I(theparentorlegalguardian)oftheapplicantstatethathe/sheisingood/normalhealth,hasnophysicalormentalhandicapsthatwouldinterferewithfullparticipationintheprogramandhasmypermissiontoengageinallavailableactivitiesexceptasnotedunderRestrictionsorModificationsabove.

Incaseofamedicalemergency,accidentorhealthproblemwhereimmediatetreatmentisdeemednecessary,everyeffortwillbemadetoexpeditiouslycontacttheparent(s)orguardian(s)oftheparticipant,ortheemergencycontactpersonlistedabove.IntheeventIcannotbereached,IherebygivepermissiontothephysicianselectedbytheRegionalUSYDirector,ChapterChaperone,orhis/herdesignee,tohospitalize,secureproperandongoingtreatmentandtoorderinjection,anesthesia,or surgery for my child as named above. I am aware that this form may be photocopied for use by medical care givers. This release will remain in effect for the 2014-2015 Kadima season from date signed until 6/30/15. I will notify the advisor if there is any change in my child’s insurance information.

Signature of Parent Date

Print Name Date