PJTC Youth Group Registration 2023-2024

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Welcome to Machar, Kadima, and USY registration! Please fill out this form to the best of your ability. If you are unsure about something and need to make a correction later, we can always go back in and edit the form on your behalf.

We are proud to announce that we will be continuing our Machar (TK-2nd grades) program that we piloted during the 2022-2023 year!

PARENT/GUARDIAN INFORMATION:
Please put whomever you prefer be the primary contact as Parent/Guardian #1.

Parent/Guardian #1 First and Last Name

Parent/Guardian #1 Email

Street Address

Street Address Line 2

City

Zip Code

Parent #1 Phone

Parent/Guardian #1 Occupation

Parent/Guardian #1 Preferred Contact Method

Parent/Guardian #2 First and Last Name

Parent/Guardian #2 Email

Parent/Guardian #2 Phone Number

Parent/Guardian #2 Occupation

Parent/Guardian #2 Preferred Contact Method

Is Parent/Guardian #2's address the same as above?

SameDifferent

Street Address

Street Address Line 2

City

Zip Code

How many children are you registering?

STUDENT INFORMATION:

Student 1 First and Last Name

Birthday

Preferred Pronouns (He/Him, She/Her, They/Them, etc.)

Student 1 Email (If Student Has)

Student 1 Cell Phone Number

Grade (Fall 2023)

School

Student 2 First and Last Name

Birthday

Preferred Pronouns (He/Him, She/Her, They/Them, etc.)

Student 2 Email (If Student Has)

Student 2 Cell Phone Number

Grade (Fall 2023)

School

Student 3 First and Last Name

Birthday

Preferred Pronouns (He/Him, She/Her, They/Them, etc.)

Student 3 Email (If Student Has)

Student 3 Cell Phone

Grade (Fall 2023)

School

Student 4 First and Last Name

Birthday

Preferred Pronouns (He/Him, She/Her, They/Them, etc.)

Student 4 Email (If Student Has)

Student 4 Cell Phone

Grade (Fall 2023)

School

EMERGENCY CONTACT INFORMATION:
In the event of an emergency, we will contact the person(s) listed above in the parent/guardian information. In the event that we are unable to reach the above person(s), please list an additional local contact in case of emergency.

Emergency Contact Name

Emergency Contact Phone

Relationship to USYer

HEALTH INFORMATION:

We understand that portions of this section of the form are subject to change. Please contact us to update the form if there is a change in your child's health information.

Please note that information shared will be kept in the strictest of confidence. We request this complete information because in addition to on-site programming, we offer off-site and overnight programming, and our programming usually does not have parent attendance.

Insurance Company Name:

If you are filling out this form for more than one child, we assume the insurance is the same for the whole family. If that is not the case, please send us an email with additional info.

Insurance Cardholder's Name:

Insurance ID Number:

Group Number:

Policy Number:

BIN Number:

PCN Number:

Physician's Name:

Physician's Phone Number:

Student 1 Health Information:

Has your child ever had or been diagnosed with any of the following? (Please check those that apply.)

ADD/ADHDAllergiesAsthmaAspergers/AutismBirth Defects/DevelopmentalCystic FibrosisDiabetesEating/Weight DisorderEmotional DisorderHeart Defect/DiseaseOperations/Serious InjuriesNeurological Issue (Including Migraines)Physical LimitationsSeizures

Please provide details for any of the medical conditions you checked in the previous question and to any disability or chronic/recurring illness not listed.

Current Medications:

Student 2 Health Information:

Has your child ever had or been diagnosed with any of the following? (Please check those that apply.)

Please provide details for any of the medical conditions you checked in the previous question and to any disability or chronic/recurring illness not listed.

Current Medications:

Student 3 Health Information:

Has your child ever had or been diagnosed with any of the following? (Please check those that apply.)

Please provide details for any of the medical conditions you checked in the previous question and to any disability or chronic/recurring illness not listed.

Current Medications:

Student 4 Health Information:

Has your child ever had or been diagnosed with any of the following? (Please check those that apply.)

Please provide details for any of the medical conditions you checked in the previous question and to any disability or chronic/recurring illness not listed.

Current Medications:

The information on this form is accurate, complete, and all-inclusive, to the best of my knowledge. I understand the importance of keeping this information accurate and agree to contact the staff prior to any program that my child(ren) will attend if there is a change of any kind whatsoever in their medical condition.

Signature of 1st Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of 2nd Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

CONSENT FORMS:

Please take a few minutes to complete this transportation consent, medical release, and medical history form. This form must be submitted to the PJTC Youth Department every year for each USYer/Kadimanik in the Chapter. No one will be permitted to attend Chapter or Regional events without this form on record.

Transportation Consent

I acknowledge and accept USY’s policy to use licensed drivers over the age of 18 at all times. With full understanding of this policy and the risks involved I give permission for my child(ren) to ride in a properly insured vehicle driven by a licensed driver over the age of 18.

Signature of 1st Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of 2nd Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

If there is a shortage of drivers over the age of 18:

I give my consent for my child(ren) to ride with a fully licensed driver under the age of 18.I do not give my consent for my child(ren) to ride with a fully licensed driver under the age of 18.

If there is a shortage of licensed drivers over the age of 18:

I give my permission for my USYer, who has a valid driver’s license (not provisional license), to drive other USYers during an event. Their vehicle is in good working order and is covered under a liability insurance policy.I do not give my permission for my USYer to drive other USYers during an event, or this is not applicable to my child(ren).

Name(s) of USYer(s) Approved to Drive:

(If Applicable)

Signature of 1st Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of 2nd Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Medical Release

I consent and give permission for my child(ren) to attend and participate in all planned trips and activities arranged by PJTC USY & Far West Region USY for which they are registered. I certify that my child(ren) is/are physically and psychologically able to participate in all such activities. In case of emergency, I authorize you, Pasadena Jewish Temple & Center, Far West USY, and related staff as my agent and at my sole cost and expense, to engage appropriate healthcare providers to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization, or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions.

Signature of 1st Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of 2nd Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Release and Indemnification

I expressly release and indemnify you, Pasadena Jewish Temple & Center, Far West USY, and related staff, and hold you free and harmless, from any and all liability, charges, claims, costs and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with acceptance and participation of my child(ren) in your scheduled activities. This release and indemnification is unconditional and without reservation of any kind, except only for such acts or omissions that arise out of your intentional or negligent wrongdoing, and where there is no fault by my child(ren). I am fully responsible if I fail to disclose any pertinent information.

Signature of 1st Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of 2nd Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Release of Name and/or Image

I consent and give permission for my child(ren) to be photographed/filmed while participating in USY/Kadima/Machar events and for such photographs to be used in various media publications, formats, including, but not limited to web pages, newspaper articles, publications and/ or newsletters. Children's names will not be used in captions without express additional consent for the particular photo or video being used.

Signature of 1st Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of 2nd Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Do you have any restrictions? (e.g. Do not want child's name next to photograph)

This Consent, Authorization, and Release ("Consent") is provided to the Region's Department of Youth Activities, ("USY"), headquartered in Encino, California, in connection with the scheduled programming. This Consent extends to and includes the United Synagogue of Conservative Judaism, Pasadena Jewish Temple & Center, and all respective agencies, departments, regions, and authorized employees, agents and volunteers.

1. The child(ren) has/have Parent/Guardian's consent to attend and to participate in scheduled activities. There are no limitations or restrictions of any kind whatsoever in such participation unless checked below and specific written instructions are attached.

There are no limitations or restrictions.There are limitations and/or restrictions, and a full explanation is in the following box.

Explanation of Limitations or Restrictions:

2. The child(ren) has/have been instructed of and understands and agrees to comply with all rules, regulations and the Code of Conduct established by USY and the official instructions and directives of all authorized staff members, volunteers, agents and employees of USY ("Personnel"). All references to YOU or YOUR mean USY and its Personnel.

3. YOU, acting as the Parent/Guardian's authorized agent and at Parent/Guardian's sole cost and expense, are expressly authorized to engage appropriate health care providers to administer, prescribe and/or direct the administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if YOU are not able to timely contact Parent for instructions. There are no exceptions or limitations to the forgoing, unless checked below and specific written instructions are attached.

There are no exceptions or limitations.There are exceptions or limitations, described in the following box.

Description of Exceptions or Limitations:

4. Unless checked below, and specific written instructions, directions, or other data to the contrary are attached, YOU may rely on our representation that the USYer(s) has/have no medical disabilities, allergies, or other limitations of any kind whatsoever that might in any way limit participation in the scheduled activities.

There are no medical disabilities, allergies, or other limitations.There are medical disabilities, allergies, or other limitations, described in following box.

Description of medical disabilities, allergies or other limitations

5. I expressly release and indemnify YOU, and hold YOU free and harmless, from any and all liability, charges, claims, costs and expenses of every kind and nature whatsoever, including reasonable attorney fees, in connection with acceptance and participation of my child(ren) in YOUR scheduled activities. This release and indemnification is unconditional and without reservation of any kind, except only for such acts or omissions that arise out of YOUR intentional or negligent wrongdoing, and where there is no fault by my child(ren). I am fully responsible if I fail to disclose any pertinent information now or as it arises.

6. Parent(s)/Guardian(s) represents to YOU that the undersigned Parent(s)/Guardian(s) have sole, full, and legal power and right to execute this Consent, and acknowledges that YOU will be relying on Parent/Guardian's representations and statements, and on the information supplied by Parent/Guardian.

7. If this consent is signed by more than one person, all references to the singular shall include the plural, jointly and severally.

Both parents' signatures are requested. In the event of a separation or divorce, only signature of the custodial parent is required.

The undersigned, respectively, declare under penalty of perjury under the laws of the States of California, that they have read and fully understand the importance and effect of the foregoing Consent, Authorization, and Release; that they have obtained such advice from an attorney and from a licensed physician as they deemed necessary to their complete satisfaction; that they have retained a true copy of this document; and that they have voluntarily signed this document on.

Signature of 1st Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of 2nd Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

The Code Of Conduct applies to behavior during both PJTC and Far West USY Regional Programming, which includes Kadima. Please ensure your USYers/Kadimaniks read through and understands this Code, as their signature is also required here. We understand that some of this information may not yet "apply" to Machar and Kadima participants. Please go through any parts of the Code of Conduct you deem appropriate with your child. USYers must read and sign the Code of Conduct in its entirety. This Code of Conduct is derived from the Far West USY Code of Conduct for overnight events, so not every aspect will apply to every event.

PJTC USY Code of Conduct

1. There will be proper conduct at all times. Treat all people with respect and courtesy. Try to be a positive leader and a good example. Theft, other illegal conduct of any kind, or flagrant violation of this Code of Conduct—as determined by the Staff—shall be sufficient reason to send you home and place you on probation at the Youth Department. This may mean an inability to participate fully in both PJTC and Regional programming.

2. No one may leave a program at any time other than the end of the program unless prior permission is given by the Staff with written permission of a parent or guardian. Participants must stay in designated program areas and may not wander off to other areas of the event's campus.

3. Hotel property, USY and PJTC property, buses, and other property that are used/visited during the event are to be respected at all times. USYers are responsible for damages or charges to their room or other locations.

4. Possession or use of the following is not permitted: weapons, alcoholic beverages, illegal drugs, cigarettes, vapes, marijuana, matches, lighters, and incense. Anyone found in violation of these or any criminal offense will automatically be sent home and suspended from International/Regional USY Programs for a period of one year, as well as potential consequences from PJTC USY as well.

5. Unless the event has a specifically stated open door policy, participants are not permitted in the rooms of those with differing gender identities. If the event has an open door policy, visiting is permitted only during the designated times, provided all drapes, window coverings, and inside doors are open. Inappropriate sexual conduct (regardless of USYers' gender identity)—as determined by the Chapter Staff and Regional Staff—is forbidden at all times and may result in expulsion from the program.

6. Gambling, body piercing, and hazing of every kind are prohibited. (Regarding body piercing, this means you may not pierce a body part during events.)

7. The daily schedule is to be followed at all times. You are to attend and be on time to all programs.

8. Prescription medicine must be registered with Staff according to the given guidelines of an event, when applicable.

9. For social programs with our local PJTC chapter, kippot are encouraged but not required. All members must wear a kippah/appropriate head covering during religious services. All members over the age of b'nai mitzvah are required to wear a tallit when on the bimah.

10. Kashrut is to be observed at all times during in-person events. If you are not sure if a product is kosher, ask a knowledgeable Staff. If no Staff are present, do not eat it. Meals that utilize the PJTC kitchens must be kosher. Meat meals must always be kosher. Outside food may be brought on the PJTC campus and eaten on disposable plates, but must be kosher-style (no non-kosher meat or fish, no mixing dairy and meat products, paying attention to hidden ingredients such as the gelatin in marshmallows). On field trips, participants are asked to choose vegetarian or kosher-style fish options. If you are unsure, just ask a Staff member.

11. Shabbat is to be observed. Shabbat is a day of rest, when we are supposed to refrain from work, using anything with an "on/off" switch, and money exchanges. This can be tricky to follow in our modern era! At PJTC this means we avoid writing, using electronic devices including phones, and exchanging money. The Youth Director's phone will be on in case of emergencies.

12. It is understood that the entire program is under the direction of the Regional Director of the Department of Youth Activities of The United Synagogue of Conservative Judaism or their designate.

13. RSVPs are required for all programming for all PJTC USY/Kadima/Machar programming unless otherwise specified in program advertising. While we encourage youth empowerment wherever possible, in this case we require that a Parent/Guardian send this RSVP. Once an RSVP has been received, the Youth Director must be notified if the USYers/Kadimanik no longer plans to attend. This is to ensure we know the safe whereabouts of everyone, and to prevent the group from waiting on an attendee who isn't planning to attend. PJTC USY reserves the right to charge, at-cost, a fee for the program if supplies/tickets/food was purchased prior to a cancellation of an RSVP.

14. Being on time to PJTC events is essential. If we think you are joining us and you aren't there yet, it is our job to worry about your whereabouts and your safety. This prevents us from starting the program with those who were on time! Not only do we need to know where you are for safety reasons, but also the first portion of almost every event is focused on peer bonding and requires full attendance to ensure success. Punctuality is also an important life skill! If you are running more than 5 minutes late for a PJTC program, you are required to send a text message or email to the Youth Director (Emily). Do not call the PJTC main office.

15. One of the goals of our youth program is Jewish peer bonding. Parents/guardians are kindly asked to refrain from "hanging out" at programs, unless serving as a designated chaperone, attending a parallel program for adults, or in cases where program advertising explicitly encourages parents/guardians and/or family members to attend.

We have read the Code of Conduct and agree to its terms.

Signature of Child

(Typing my name will have the legal effect of my signature.)

Signature of Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of Child

(Typing my name will have the legal effect of my signature.)

Signature of Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of Child

(Typing my name will have the legal effect of my signature.)

Signature of Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Signature of Child

(Typing my name will have the legal effect of my signature.)

Signature of Parent/Guardian:

(Typing my name will have the legal effect of my signature.)

Dues:

Due to increases in costs across the board, we are nominally increasing our suggestion for dues for the 2022-2023 year. These dues go directly to chapter programming and staffing. Why pay dues? Depending on the event dues-paying members receive either free attendance or a discount on the cost!

All of our dues are on a "pay-what-feels-right" basis. Those who can pay more will help those who cannot. Once you become a dues-paying member, the programs you attend will be free or at a lower cost to you than to non-dues-paying participants. You must become a dues-paying member to have access to program & summer camp scholarship funding.

MACHAR (TK-2nd Grades): Pay-what-feels-right! We suggest between $30-$75 per member.

KADIMA (3th-6th Grade): Pay-what-feels-right! We suggest between $50-$95 per member.

USY (7th-12th Grades): Pay-what-feels-right! We suggest between $70-$115 per member.

What if I just want to try it out first? Sure! You are welcome to attend local PJTC USY/Kadima/Machar events without becoming a dues-paying member. That just means you might have to pay more for the first few local events you attend before you are totally hooked and realize you should just become a member! We’ll still need a parent/guardian to fill out the permission forms above. You can leave the donation lines (below) blank for now.

Name of Student:

Amount Donated ($):

Name of Student:

Amount Donated ($):

Name of Student:

Amount Donated ($):

Name of Student:

Amount Donated ($):

HOW TO PAY:

1. Credit Card (Preferred)
2. Bill My Account (You must be logged in for this option.)
3. Mail a Check* (You must be logged in for this option. Select "Bill My Account.")

*Checks should be made out to Pasadena Jewish Temple & Center, and please put “USY/Kadima/Machar Dues” in the memo line.*

Is there anything else you think we should know about your student or family?

Thu, May 9 2024
1 Iyyar 5784

Shabbat Services

All are welcome to join our in-person services every Friday at 7:30PM and Saturday at 9:30AM.

You can also attend services virtually through Zoom, please contact the office to receive the link.

Services will not be available online Friday, April 26.

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Thu, May 9 2024 1 Iyyar 5784