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Youth Group Registration

Jewish Community Youth Group Registration

Please complete all sections of this application:

FAMILY INFORMATION:
Parent/Guardian Name (1)*

(Full Name of Parent/Guardian 1)
Mailing Address (1)*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Email (1)*
Parent/Guardian Cell Phone # (1)
Do you have a home phone to include?*
- Yes
- No
Parent/Guardian Home Phone #
(Home phone number of Parent/Guardian 1, if you have one)
Is there another Parent/Guardian to be listed?*
- Yes
- No
Does this Parent/Guardian live at the Address above?*
- Yes
- No
Parent/Guardian Name (2)*

(Full Name of Parent/Guardian 2)
Parent/Guardian Address (2)*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Email (2)
Parent/Guardian Cell Phone # (2)
Children's Address*
Street Address Address Line 2 City State ZIP Code
Congregation Affiliation:
The term affiliation means you have a registered membership and are current in your financial obligation with either Temple Beth Tikvah, Congregation Shalom Bayit or Chabad.
Which congregation are you affiliated with?*
- Temple Beth Tikvah
- Chabad of Central Oregon
- Shalom Bayit
- Not affiliated with any of these congregations
How many children are you registering for Youth Group?*
- 1
- 2
- 3
Student Participant emails
When enrolling participants, please include the best email address for contact, whether student's or parent's.
Name of Participant 1*

(Full Name)
Birthdate for Participant 1
MM slash DD slash YYYY
Grade (in Sept) for Participant 1*
Gender Identification 1
Participant 1's email
Participant 1's phone
Name of Participant 2*

(Full Name)
Birthdate for Participant 2
MM slash DD slash YYYY
Grade (in Sept) for Participant 2*
Gender Identification 2
Participant 2's email
Participant 2's phone
Name of Participant 3*

(Full Name)
Birthdate for Participant 3
MM slash DD slash YYYY
Grade (in Sept) for Participant 3*
Gender Identification 3
Participant 3's email
Participant 3's phone
NOTE: If you have more than 3 children to register, please submit those extra names, birthdates, grades, and Religious/Hebrew school selections via email to the TBT Treasurer at TBTtreasurer@gmail.com.
YOUTH GROUP FEES: Annual dues for participants are $50; this year that is prorated to $20 as we are only meeting for a portion of the year. 7th graders registered for Sunday Religious School can participate for no fee as this is included in tuition.
Participant 1 Youth Group
Price:
Participant 2 Youth Group
Price:
Participant 3 Youth Group
Price:
YOUR TOTAL SCHOOL TUITION FEES: $
$0.00
Planned Payment Method: If paying by check, please make your checks payable to Jewish Community Religious School and mail to P.O. Box 7472 Bend, OR 97708. If paying by credit card, there is an opportunity for payment after submitting this form.
Payment method:*
- Check (preferred)
- Credit Card
HEALTH INFORMATION & EMERGENCY CONTACT: Please complete the following:
Do all of the enrolled participants have the same doctor?*
- Yes
- No
Doctor's Name*
Doctor's Phone #*
Doctor's Name - participant 2
Doctor's Phone - participant 2
Doctor's Name - participant 3
Doctor's Phone - participant 3
In case of an emergency, parents will be contacted first. If parents cannot be reached, the emergency contact will be called.
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Do any of your children have allergies, medical issues or food restrictions?*
- Yes
- No
Please list each child's name and an explanation of any health issues in the box below.
Health Issues
After completing your Youth Group Registration and CAPTCHA prompt, click the "Submit" button and wait for the Thank You confirmation message; this may take a few seconds. Your completed Registration is transmitted to our Treasurer for further processing.

You will receive a confirmation email, with information on making your payment. If you should have any problems, please contact us at: sjfskier80@gmail.com
CAPTCHA

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CONTACT INFO

PO Box 7472
Bend, OR 97708
(541) 388-8826
templebethtikvah@gmail.com

Services are held at:
First Presbyterian Church
230 NE Ninth Street, Bend.

Shabbat Times

Artwork graciously donated by Julie Wohl.
To see more of her work,
visit Julie Wohl Creations.

Yom Shabbat, 14 Sivan 5783