CBS Youth Group Registration

CBS Youth Group

For students entering 6-12th grade

Youth Group will meet every 2nd Wednesday of the month from September through June, from 7-8:30PM.

Should you have any questions, please contact Marah.

Student Information

* Student's first name

* Student's last name

* Student's Date of Birth

* Student's email

* Student's cell #

Select student's grade in Fall of 2025 from the dropdown below.

* Allergies

If none, list "N/A"

Medical Release

I/We, the undersigned, parent(s) of

* Student's first and last name

, a minor, do hereby authorize Congregation Beth Shalom as agent for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable and is to be rendered under the general or specific supervision of a surgeon licensed under the provisions of the Medicine Practice Act. The authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective until August 2026.

Signature (please type full name)

Photos for Social Media and Promotional Purposes
We often take photos of the children during activities and events. Do you give permission for photos of your child to be featured on Congregation Beth Shalom's social media or used for promotional purposes?

Please select one.Yes, I give permission.No, I do not give permission.

Parent Information

Parent #1

* First name

* Last name

* Email

* Cell phone #

Parent #2

First name

Last name

Cell phone #

Emergency Contact

Please list an emergency contact if the parents cannot be reached.

* First name

* Last name

* Cell phone #

* Payment

PaymentThis is a one time $180 payment for all sessions of CBS Youth Group.

I would like to make an additional contribution to keep programs like this happening at CBS.

Total

Student Information

Medical Release

Parent Information

Parent #1

Parent #2

Emergency Contact

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