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USY Membership Form

ACHIM CHAPTER USY

Get involved in Herzl-Ner Tamid’s award-winning chapter! HNT is proud to subsidize USY chapter events for all participants regardless of their membership status at HNT. HNT members benefit from a higher level of subsidy, but non-member community participants are always welcome. Non-members must sign up as either a Full Member or provide credit card and authorization to bill for any events their teen attends. This will be done separately after receiving your membership form.

Membership choice:

Ragil (Regular Member):

HNT Members: $45

Community Participants: $75

Member belongs to USY Chapter and Region
Member is able to attend all Chapter and Regional events
Member pays for each event that he/she attends

Shalem (Full Member):

HNT Members: $100

Community Participants: $130

Member belongs to USY Chapter and Region
Member is able to attend all Chapter and Regional events
Member attends all Chapter events (except the Shabbaton) for free (includes Shabbat Services & Dinner and outings)
Regional Kinnusim, International Convention, and transportation are not included

Please do not let financial concerns keep you from joining. Contact Leslie Reibman, Program Director, for confidential assistance at (206) 232-8555 ext. 207.

First Name
Last Name
Age
Grade
Birth date
Teen’s Email
Address
City
State
Zip
Phone: Parent Information
Parents’s Email
Parent’s Name
Cell Phone
Parent’s Name
Cell Phone: Membership
Membership Choice
Current HNT Member: Emergency Contact (not parents)
Name
Relationship
Phone
Name
Relationship
Phone: Insurance, Release, and Payment Information
Parent Insurance Policy
Medical Insurance Number
Does HNT have your permission to publish your child’s name, age, grade, phone number and address in a roster for USY members only?
My son/daughter has my permission to participate in all USY activities s/he chooses to attend. I release Herzl-Ner Tamid from legal responsibility for my son/daughter.
I would like to pay

USY Membership Form

ACHIM CHAPTER USY

Membership choice:

Ragil (Regular Member):

Shalem (Full Member):

Parent Information

Membership

Emergency Contact (not parents)

Insurance, Release, and Payment Information