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Jewish Youth Orchestra



Participant Information

Male
Female

as of 01/2018

(optional)

This email address will ONLY be used for JYO correspondence.

Additional Participant Information (Sibling)

Male
Female

as of 01/18

(Optional)

This email address will ONLY be used for JYO correspondence.

Parent Information

Both Parents
Mother
Father
Other

Name & Relationship to child

• I release Jewish Federation from all responsibilities other than rehearsal space and supervised youth orchestra-related activities.

• The undersigned consents to the use of the paticipant’s name, photograph, or other identification in connection with the Jewish Federation’s programs, exchanges or publicity.

Child's Name

Child's name

• I consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of a licensed hospital, whether such examination, diagnosis or treatment is rendered at the office of said physician or at such hospital.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Fall Semester $100.00
Spring Semester $200.00

You will have the option to make up to 4 monthly payments at check out.

Fall Semester $80.00
Spring Semester $120.00

You will have the option to make up to 4 monthly payments at check out.

Account Details

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

Payment Information

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