Leave this field empty

USY Membership Form & Waiver 2019-2020

Membership in USY entitles you to attend any local and regional events.  Cost is $40 payable to Park Synagogue. Please return this form with dues to Rabbi Marcus at Park Synagogue, 27500 Shaker Blvd, Pepper Pike, OH 44124 or fill out and pay online at parksynagogue.org

if applicable


My child has my permission to go on and participate in educational field trips sponsored by The Park Synagogue Youth Groups at any time during the 2019-2020 school year. I understand my child will travel by bus or private car and will be accompanied by staff and/or parents. I release The Park Synagogue, its agents (whether or not compensated, and including parents of other students or other chaperones) and employees from all liability during or arising in connection with or from any such activities, and waive any and all claims that I or my child may have against The Park Synagogue or any of its officers, trustees, agents or employees as a result of my child participating in any such trip or activity. I also authorize any such agent or employee of The Park Synagogue to obtain medical advice, services and/or treatment for my child if such person reasonably deems any such medical advice, services and/or treatment to be necessary or advisable provided that such person first makes a reasonable attempt to notify me by telephone at the number below if circumstances permit.

I agree to notify The Park Synagogue Youth Groups if at any time the above information is changed or incorrect. The Park Synagogue is entitled to rely on the above information and any additional information about my child of which I inform you in writing. I and my child clearly understand that no smoking or drugs, other than those prescribed by a licensed physician will be permitted on any trip. I and my child also understand that, in the event of behavior unacceptable to The Park Synagogue agents or employees, you will send my child home at my expense after making a reasonable attempt to notify me.

Note: This trip waiver covers all trips during the school year. You will be notified, in advance, about each trip, which will state destination, departure and return times, and method of transportation.


I/We [Parent(s) Name(s)] hereby grant permission to [Hospital Name] Hospital and the emergency room physician to administer any emergency treatment deemed necessary. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

[Emergency Contact] (person to contact if unable to reach parents) has the authority to give additional instructions and consent if parent cannot be reached.

Child's Medical History

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

For added Security please check the box below.