2013 USY Summer Program Early Bird Registration

  • Select a Program:
  • Applicant Information

    Name (as appears on birth certificate or passport):



    *Please note that the charge will be in American dollars.

    Home Phone:

    Applicant's Email Address:

    Parent 1 Information

    Parent 1 Name:

    Home Address (if different from Applicant):

    Parent 1 Phone (if different):

    Parent 1 Fax:

    Parent 1 Email:


    Business Address:

    Business Phone:

    Parent 2 Information

    Parent 2 Name:

    Home Address (if different from Applicant):

    Parent 2 Phone (if different):

    Parent 2 Fax:

    Parent 2 Email:


    Business Address:

    Business Phone:

    Applicant lives with:

  • Grade as of Sept. 2012:
  • Date of Birth:

  • Male
  • Female
  • Applicant's T-Shirt Size:
  • Synagogue:

    USY Chapter:

  • Region:

  • Payment Information

    Payment Option:


    Type of Credit Card:

    Card Number (no dashes):

    Expiration Date - mm/yy:

    Three-Digit Security Code (on back of card):

    Many applicants are in need of financial assistance to participate in the program:

  • Please check here if you wish to make a voluntary contribution of $100 to our scholarship fund which will be added to your tuition, so that we can help those in need of assistance. Thank you.
  • Please check here if you would like to receive information about Tikun Olam Scholarships available from your region.

  • I hereby apply for enrollment of my child for his/her participation in the program indicated above. I agree to all terms of payment. I understand that USY summer programs are only open to USY members and that my child will be required to join a USY chapter prior to final acceptance. I also understand that all USY program participants must be Jewish (i.e., born to a Jewish mother or converted to Judaism).

    A $750 deposit is required in order to reserve your spot and qualify for the Early Bird discount. Final prices are set to be announced around November 15, 2012. Once prices are officially announced, you will be notified immediately and you will have 2 weeks to cancel without penalty. After this two-week period has concluded, should an application be withdrawn for any reason, a $150 processing fee will be withheld provided such written cancellation is received by March 1, at which point additional cancellation fees will apply. All applicants must complete the second half of the early bird application once the prices are announced.

    Parent's typed signature:

    Email address for confirmation: