Youth Engagement Form 2023

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Shalom! Please complete this form for each youth in your family. This form is used to prepare programming and for communications to all our B'nai Amoona member families for all of our B'nai Amoona youth programs and events.

If you have any questions, please contact Liessa at Liessa@bnaiamoona.com.

For help completing the form, please contact Tanya at tanya@bnaiamoona.com.

Youth's Basic Information

* Youth's First Name

* Youth's Last Name

* Youth's Birthday (MM/DD/YYYY)

Youth's Email

Youth's Cell Phone

Youth's T-Shirt Size

As B’nai Amoona is an inclusive Synagogue, we ask that you please share your preferred pronouns.

Please write in one of the options below:

He/Him
She/Her
They/Them
Xe/Xim/Xis
I prefer not to answer

Youth's Allergy / Medical Information

* Does your youth have any food allergies?

If you answer YES we will be sending you a FOOD ALLERGY ACTION PLAN to fill out.

Please list the food allergies below

Please review any information in the box above. Any changes made will be applied to your youth's account and will override any current information on file.

* Does your youth have any non-food allergies?

If you answer YES we will be sending you an ACTION PLAN to fill out.

Please list the non-food allergies below

Please review any information in the box above. Any changes made will be applied to your youth's account and will override any current information on file.

* Does your youth take any medications?

Please list current medications below

Please review any information in the box above. Any changes made will be applied to your youth's account and will override any current information on file.

* Does your youth have any additional medical concerns?

Please list any additional medical concerns below

Please review any information in the box above. Any changes made will be applied to your youth's account and will override any current information on file.

Adult's Basic Information

* Adult 1's First Name

* Adult 1's Last Name

* Adult 1's Email

* Adult 1's Cell

Preferred Contact Method

Please Select OneVoice CallText MessageEmail

Adult 1's Relationship to youth

Adult 2's First Name

Adult 2's Last Name

Adult 2's Email

Adult 2's Cell

Preferred Contact Method

Please Select OneVoice CallText MessageEmail

Adult 2's Relationship to youth

We recognize that there are many people involved in our youth 's lives. Please list below any additional people who should receive communication about your youth.

Adult 1's First Name

Adult 1's Last Name

Relation to youth

Adult 1's Email Address

Adult 1's Phone Number

Please select which communications Adult 1 should receive

All Communications related to the childBnai Amoona Family ProgramingCamp ProgrammingEarly ChildhoodMKLC (Religious School)Youth Programming

Adult 2's First Name

Adult 2's Last Name

Relation to youth

Adult 2's Email Address

Adult 2's Phone Number

Please select which communications Adult 2 should receive

All Communications related to the childBnai Amoona Family ProgramingCamp ProgrammingEarly ChildhoodMKLC (Religious School)Youth Programming

Grade Level Youth Programming

Congregation B'nai Amoona will be hosting Social Grade Level Youth Programming once a month on Sunday afternoons. Programming will be offered for Grades 3-5th and then 6-8th Grades. Lunch will be served from 11:30- 12:00 followed by a youth activity outside of the building. There will be an additional fee associated with this program. ( $15-$30)

Please let us know your plans!

At B'nai Amoona, we strive to be inclusive to our families and do not wish to have our programming be a burden on any family. Please reach out to Liessa at liessa@bnaiamoona.com or call her at 314-576-9990 x 116 if you have any questions.

Please help us plan for this coming year in ways that are best for your family!

My youth is PreK age ( the year before Kindergarten) and I'm interested in them attending Sunday morning programming if it is offered.

My youth is in grades K- 2nd and I would be interested in having them participate in a social activity on Sunday mornings from 11:30- 1:00 pm.

My youth would be interested in the following optional Programming on Sundays from 11:30- 1pm:

ChessArtDramaSports

I am interested in an Overnight Social Experience this year for my youth during the school year. Whether it be at B’nai Amoona or at a campsite nearby.

I am interested in serving on a Youth Committee for B'nai Amoona.

Setting up your Youth for Success

* Student's Secular Grade - Fall 2023

* Student's Secular School - Fall 2023

We want your youth to feel supported and successful at B’nai Amoona. We cannot do this without your partnership. We want to be a place they feel cared for and “seen”. Each of us has things that make us unique. Each of us has something that bothers us. Each of us has “best ways” for us to learn and grow. Please help us get to know your student and family so, together, we can create a place of laughter, learning, and love.

My youth learns best by:

SeeingDoingHearingWriting

My youth tends to be more:

OutgoingReserved

My youth tends to (___) going to B'nai Amoona.

LikeDislikeN/A

My youth tends to:

Enjoy making new friendsHang out with the same students at all timesFeel like they have lots of friends at B'nai AmoonaFeel like they do not have friends at B'nai Amoona

My youth is:

ArtisticInterested in sportsLoves theaterEnjoys video gamesOther

Other

My youth plays a musical instrument:

Please Select OneNoYes

Please list instrument

My youth enjoys singing:

Please Select OneNoYes

Please list types of music

Just like in school, we want to support your youth in their specialized needs. We can only do this if we are able to partner with you and have the information we need to create the best program for them.

Please share with us some of your youth’s greatest strengths and areas in which they are most proud. This may include: being social and friendly comes easy to them, they love learning about new things, they are great at sports, they are involved in theatre, they are very easy going, etc.

Please take a few minutes to share with us any information about your youth that may affect their ability to feel and be successful at B'nai Amoona.

Does your youth have any social / emotional concerns?

Please list their concens

Please review any information in the box above. Any changes made will be applied to your youth's account and will override any current information on file.

Does your youth have any learning challenges?

Please list their learning challenges

Please review any information in the box above. Any changes made will be applied to your youth's account and will override any current information on file.

Does your youth have an IEP (Individualized Education Plan ) or 504 plan?

*If “yes,” we will call to discuss this with you further.

Please email a copy of your youth's IEP or 504 plan to Liessa Alperin at Liessa@bnaiamoona.com. This will be kept confidential, but be used to create the best learning plan for your students.

Please review any information in the box above. Any changes made will be applied to your youth's account and will override any current information on file.

Social Media / Advertising

* Please choose your level of social media representation for your youth

Please Select OneVideo and photographic stills of my youth are allowed to be used in advertising and social media outlets such as B'nai Amoona's website, bulletin, public Facebook page, the Jewish Light, etcVideo and photographic stills of my youth are only allowed in a closed social media space such as a private B'nai Amoona Facebook groupNo video or photographic stills of my youth are allowed on any form of social media or advertising for B'nai AmoonaPlease contact me prior to posting video or photographic stills of my youth

Waivers and Authorizations

In the event that the adult or emergency contacts provided cannot be reached in an emergency situation involving my child, I hereby assign authority to Congregation B’nai Amoona to act in my behalf in authorizing such emergency treatment as necessary.

In cases of extreme emergencies, your child will be brought by ambulance to the nearest hospital.

In cases of extreme emergencies, your child will be brought by ambulance to the nearest hospital.I agree to the above statement.

We will treat students with Band-Aids, antibiotic ointment (i.e. Neosporin), or ice packs in case of injury. We will NOT treat a child with oral medication without written or oral consent (via telephone) by a parent/legal guardian.

Please Select OneI-agree-to-basic-medical-treatmentI do not agree to basic medical treatment

I hereby authorize my child to go on any field trip deemed appropriate by the director in conjunction with the programs for which my child is registered. Congregation B’nai Amoona may transport my child on field trips by whatever means it deems appropriate. The undersigned hereby releases and forever discharges Congregation B’nai Amoona, the agents, servants, and employees from any and all claims, actions, or causes of actions resulting from sickness or accidental injury.

Please Select OneI agree to allow my child to attend all field tripsPlease contact me prior to each field trip my child may be attending for my consent

In an emergency, I request the Director or designee to contact the home or one of the relatives/friends listed. If unable to contact anyone, I hereby authorize the school to make such arrangements as seem necessary, and I also authorize the hospital and physician to perform necessary procedures. I prefer my child to be taken to __________ Hospital or a nearby hospital if deemed necessary. Costs of the medical attention and ambulance are responsibility of parent/guardian. It is understood and agreed that Congregation B’nai Amoona, or its agents, servants, and employees shall not be liable for any claims, actions, or causes of action arising out of any conduct authorized here, and the undersigned hereby specifically releases the Congregation B’nai Amoona and its agents, servants, and employees from any and all such claims, actions, or causes of action.

Please indicate your preferred hospital below

Please check the appropriate box indicating who may pick up your child in the event of a disaster:

Please Select OneMy child may only be picked up by his/her parent or guardian.My child may leave with anyone he/she feels comfortable riding with (relatives, neighbor, etc.)My child may be picked up by anyone he/she feels comfortable with except the following people

Please list the people below who are NOT authorized to pick up your child

* Are you enrolling your child in MKLC for the 2023-24 school year?

Please choose oneYes, I will attend MKLC this yearI am a Mirowitz student who will only attend on SaturdaysNo, I will not be attending MKLC this year.Yearly Fees:

NO PREK THIS YEAR
K, 1st, & 2nd Grade: $400
3rd - 6th Grade: $800
7th Grade: $800 *
8th Grade: $400
9th & 10th Grade: $300
11th & 12th Grade: $136

*Tuition may be reduced based on your student’s B’nai Mitzvah date.

There's no fee for Mirowitz students attending on Shabbat.

* Student's Religious School Grade - Fall 2023

Meyer Kranzberg Learning Center - Religious School

MKLC will be held in person this year. Classes will be held on Sundays and one Saturday a month (which will replace Sunday Morning). In addition, 3rd - 6th grade will also attend in person on either Tuesday or Wednesday.

For some information about this year’s MKLC programming and NEW-ish Midweek
structure click below:

MKLC 5784 Calendar

Kindergarten, 1st & 2nd Grade at MKLC

Frequently Asked 3rd through 6th Grade Midweek Questions

7th through 10th Grade at B’nai Amoona

Please choose which class your child will be attending

Tuesday ChuggimWednesday ChuggimMy child is not a 3rd-6th grader / My child attends MirowitzOur Mid Week Chuggim Program is being offered for 3rd-6th graders. Please choose the best day for your family. We recognize families may need to change their day throughout year.

Click here for a PDF with more information about the program.

Please choose your payment option for MKLC

Pay in full after I receive my tuition confirmation email.Make 2 equal payments: Oct. 2023, Feb. 2024.Make 4 equal payments: Oct 2023, Dec. 2023, Feb. 2024, Apr. 2024Make 8 equal payments: Oct. 2023 - May 2024I need a different payment plan option.

Please choose your payment method

ACH (Electronic Check)Credit Card**Please note there is a 3.5% processing fee when utilizing a credit card for payment.

Please choose the day of the month to charge your Credit Card / ACH.

With signature(s) below, Credit Card or ACH authority is to remain in full force and effect until Congregation B’nai Amoona has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Congregation B’nai Amoona a reasonable opportunity to act. Charges are made on the 15th of each month unless other arrangements are made.

Please type your name

Today's Date

I would like to know more about financial assistance opportunities

I would like to know more about financial assistance opportunitiesAfter you have completed the MKLC registration, a link will be sent to you with information about financial assistance.

Thu, May 9 2024 1 Iyyar 5784