Junior Youth Group Registration Form CKA’s Junior Youth Group is our group open to our junior high/middle school age students. Please enable JavaScript in your browser to complete this form.Participant Information – Step 1 of 7Participant Name *FirstMiddleLastBirthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Participant Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParticipant Cell NumberParticipant EmailParent with which child resides *Parent 1Parent 2BothNextParent 1 Legal Name *FirstMiddleLastParent 1 Best Contact Phone *Parent 1 EmailEmailConfirm EmailIs this parent's address the same as the participant's? *YesNoParent 1 Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextIs there another parent to add? *YesNoParent 2 Legal Name *FirstMiddleLastParent 2 Best Contact Phone *Parent 2 EmailEmailConfirm EmailIs this parent's address the same as the participant's? *YesNoParent 2 Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextMy child, indicated on this form, has my permission to participate in Congregation Kol Ami’s Junior Youth Group. In consideration of my child’s acceptance as a youth group paricipant, I hereby waive any and all claims against Congregation Kol Ami, its agents, employees and volunteers, that may arise out of injury, loss or damage suffered by my child during any youth group or temple activity. I also consent for my child to be transported to and from any youth group program by school bus, coach bus, Congregation Kol Ami staff member, youth group staff and volunteers and/or by other parents or youth participants in case of carpooling. On behalf of myself, my heirs and assigns, my personal representatives, administrators and executors, and my child (if under the age of eighteen years), I do hereby release, discharge, indemnify and hold harmless Congregation Kol Ami (CKA), any and all faculty members and youth group staff members, their agents, representatives, employees and volunteers, from and against any and all claims, demands, causes of action, liabilities, damages, and personal injuries, including death, property damage, economic losses, or loss of any nature or cause including costs and attorney fees in connection with or arising from participation in any meeting, activity, or trip. This is to certify that my child is in good physical health and can participate in youth group events: *Without LimitationsWith the indicated limitations and/or accommodations:Limitations/Accomodations:NextMedication ReleaseI give permission for my child to take the following over-the-counter medications under the supervision of an adult chaperone from Temple:AcetaminophenIbuprofenAntihistamineInsurance InformationParticipant/Insured NameFirstLastInsurance Carrier NamePolicy #Group #Name of the Policy HolderFirstLastPolicy Holder Date of BirthParticipants Relationship to the Policy HolderNextCongregation Kol Ami’s Junior Youth Group has the permission of Participant’s parent or guardian to use any recording, or other depiction (whether by sound, video, photography or other means) or testimonials (written or verbal) of Participant or any family member of Participant for the purpose of promoting Congregation Kol Ami’s Junior Youth Group and its Programs, Events and activities: *I ApproveI DO NOT ApproveNextIf the participant is a minor, I further attest that I am the parent or legal guardian of the minor child and that I have the legal right and authority to enter into this agreement on behalf of the minor and myself. 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