We engage over 100 youth in the Pittsburgh community,
from kindergarten to 12th grade.
Join us for engaging, educational programming in a social and creative setting for ALL youth!
Programs include Shabbat dinners, study sessions, holiday activities, regional conventions, basketball games, ice skating, challah baking…and more.
Join us! Please print out the form below and submit with payment to Carolyn. Bring the form and check to your next youth event, or mail to Congregation Beth Shalom – ATTN: Youth Department, 5915 Beacon St., Pittsburgh, PA 15217.
Thank You!
Congregation Beth Shalom
Youth Contact Information Sheet
Name of Child: _________________________________________________________
Name of Youth Group: ____________________________________________________
Home Address: _________________________________________________________
Home Phone Number: ___________________________________________________
Child’s E-Mail:__________________________________________________________
Child’s Cell Phone: _______________________________________________________
May we contact your child via e-mail? YES _____ NO______
May we contact your child via cell phone? YES _____ NO______
May we contact your child via text message? YES _____ NO______
Child’s Birthday: ____________________
month/day/year
Grade in School, Fall 2011:________________________________________________
School: ________________________________________________________________
Parent #1 Name:_________________________________________________________
Parent Cell:______________________________________________________________
Parent E-mail:____________________________________________________________
Parent #2 Name :_________________________________________________________
Parent Cell:______________________________________________________________
Parent E-mail: ___________________________________________________________
Who should we contact in case of an emergency?
Name:___________________________________________________________
Home Number:_____________________________________________________
Cell Number:____________________________________________________
Does your child have any allergies or medical conditions that we should be aware of?: If yes please note: _________________________________________________________________________
According to new privacy laws, we need your permission to take and publish pictures of your child in synagogue or local publications.
______ I give Beth Shalom Youth Department permission to photograph my child during youth events.
______I give Beth Shalom Youth Department permission to publish photographs of my child taken during youth events.
Signature: _____________________________________________________________
Date signed: ____________________________________________________________
Please return with check to:
Congregation Beth Shalom Youth Department
5915 Beacon Street
Pittsburgh, PA 15217
Chaverim: No Fee
Atid: $18
Kadima: $36 ($50 for non-Beth Shalom members)
USY: $60 ($100 for non-Beth Shalom members)
All fees are identical to last year’s.
THANK YOU!
