Youth Group Registration Form

2009-2010

CIRCLE PROGRAM FOR WHICH YOU ARE REGISTERING:

Make checks payable to: Midway Jewish Center

            USY (Grades 9-12): MJC Member - $70   Non-Member - $80

                Kadima (Grades 5-8): FREE   (you still need to fill out form)

Name:                                                                    Grade Sept. 2009                

Address:                                                                                                                               

City:                                              State:                    Zip Code:                         

Gender:        M       F        Age:                 Birthday:                                            

School:                                                       Cell phone:                                        

E-Mail Address:                                          Home Phone:                             

Parent E-Mail Address:                                               

Would parent like to be on e-mail list?:

Is your family a member of Midway Jewish Center?       Yes        No

------------------------------------------------------------------------------------------------------

EMERGENCY CONTACT:

Name:                                                                Cell Phone:                               

Relationship to Youth Group Member:                                                         

Other phone:                                                                                                        

Registrant hereby consents to the use of their photograph, likeness or other depiction on the MJC website or in other MJC promotional material.

Parent/Guardian signature:                                                                            

Youth Group member signature:                                                                 

Medical Insurance Information (company and policy #):

------------------------------------------------------------------------------------------------------

FOR OFFICE USE ONLY

                                                 Paid                                        Date

Midway Jewish Center

Youth Group

Survey

Name:                                                                      Grade Sept. 2009           

Phone:                                        E-mail:                                                       

------------------------------------------------------------------------------------------------------

Have you been a member of this youth group before?                                 

Have you held any leadership positions?  If so, which ones?                                                                                                                                                                                         

Would you like to learn more about leadership opportunities?                   

Please list at least 3 programs that you would like to see Midway’s youth groups do this year:

1)                                                                                                                                            

2)                                                                                                                                            

3)                                                                                                                                            

Why did you join Midway’s youth group?                                                                           

How did you hear about Midway’s youth group?                                                  

Anything else you would us to know?                                                                                 

Todah Rabah – Thank You!