Anshe Emet Youth Department

Name of Child:________________

2011-2012 SHMUSY Membership Form

Page 1

Member Information (Please Print Clearly)

Child 1 English Name:___________________________ Hebrew Name:___________________ Sex: Male
Female
Birth date:_______________ School Name:___________________________________ 2011-2012
Grade:____________
Student Email:___________________________ Home Phone:______________ Student Cell Phone:
________________
Child lives with: Mother(s) Father(s) Both
_______________________________________

Other (specify)

Child 2 English Name:___________________________ Hebrew Name:___________________ Sex: Male

Female
Birth date:_______________ School Name:___________________________________ 2011-2012
Grade:____________
Student Email:___________________________ Home Phone:______________ Student Cell Phone:
________________
Child lives with: Mother(s)

_______________________________________

Father(s)

Both

Other

(specify)

Child 3 English Name:___________________________ Hebrew Name:___________________ Sex: Male

Female
Birth date:_______________ School Name:___________________________________ 2011-2012
Grade:____________
Student Email:___________________________ Home Phone:______________ Student Cell Phone:
________________
Child lives with: Mother(s)

_______________________________________

Father(s)

Both

Other

(specify)

Child 4 English Name:___________________________ Hebrew Name:___________________ Sex: Male

Female
Birth date:_______________ School Name:___________________________________ 2011-2012
Grade:____________
Student Email:___________________________ Home Phone:______________ Student Cell Phone:
________________
Child lives with: Mother(s)

_______________________________________

Father(s)

Both

Additional Member Information

Do you attend a summer camp or participate in any summer programs?
If yes, where?_______________________________________________________________________

Other

(specify)

What types of activities are you most excited about: ________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please Check One: Cubs Fan___ Sox Fan___

T-Shirt Size: __XS __S __M __L __XL __XXL

Adult Size__________ Child Size ________

Emergency Information
Emergency Contact (Other than Parent / Guardian):_______________________________________________________
Relationship:_____________________________

Home #:___________________

Work #:___________________

Please let us know of any medical limitations or dietary restrictions that will help us better provide for your child:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Release Form
I, the undersigned parent/legal guardian of __________ do hereby authorize the USY staff or agents of Anshe
Emet Synagogue to act as our agents to any medical or surgical diagnosis and/or treatment or hospital care
deemed advisable by a duly licensed physician. In the event that such help of an emergency nature becomes
necessary, Anshe Emet Synagogue, its Officers, Youth Staff, or agents will not be held liable for any first aid or
surgical treatment procedures performed pursuant to this consent.
I further give permission for my son/daughter __________ to participate in all activities that are in conjunction
with the Anshe Emet Synagogue Youth Department for the period commencing July 1, 2011-June 30, 2012, and
so hereby release Anshe Emet Synagogue, its Officers, Youth Staff, and its agents from any liability arising
from my childs participation in Youth Group activities.
I allow my childs picture to be used in Anshe Emet publicity and put on the Anshe Emet Synagogue website.
_____ (initial)
Parents/Legal Guardians Signature: __________________________
Date: _________________
If you are not a member of Anshe Emet Synagogue, fill out the reverse side.

Anshe Emet Youth Department

Name of Child:__________________
Child 1
USY (9th-12th Grade)
USY $50
Child 2
USY (9th-12th Grade)
USY $50
Child 3
USY (9th-12th Grade)
USY $50
Child 4
USY (9th-12th Grade)
USY $50

2011-2012 SHMUSY Membership Form

Page 2

KADIMA (6th-8th Grade)

KADIMA $40

MACHAR (3rd-5th Grade)

MACHAR $25

SHACHAR (SK-2nd Grade)

SHACHAR $18

KADIMA (6th-8th Grade)

KADIMA $40

MACHAR (3rd-5th Grade)

MACHAR $25

SHACHAR (SK-2nd Grade)

SHACHAR $18

KADIMA (6th-8th Grade)

KADIMA $40

MACHAR (3rd-5th Grade)

MACHAR $25

SHACHAR (SK-2nd Grade)

SHACHAR $18

KADIMA (6th-8th Grade)

KADIMA $40

MACHAR (3rd-5th Grade)

MACHAR $25

SHACHAR (SK-2nd Grade)

SHACHAR $18
Total Payment Amount:

$__________.00

Payment Information
How would you like to be charged for your child(ren)s membership?

Credit Card

Synagogue Account

Enclosed Check

Parent / Guardian Information

What synagogue does your family belong to? __________________________________________
Parent / Guardian:
Name:_______________________________________________

Home #:____________________________

Address:_____________________________________________

Work #:____________________________

____________________________________________________

Cell #:____________________________

E-Mail Address: _________________________________________________________________________________

Parent / Guardian:
Name:_______________________________________________

Home #:____________________________

Address:_____________________________________________

Work #:____________________________

____________________________________________________

Cell #:____________________________

E-Mail Address: ________________________________________________________________________________

Anshe Emet Youth Department: 3751 North Broadway Chicago, IL 60613

Questions? Call the Director of Informal Education and Youth Activities at (773) 868-5127 or check out
www.SHMUSY.org