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Family Information

Parent 1

* Name

* Occupation & Employer

Home Phone

* Cell Phone

* Email Address

* Home Address Street

* Home Address City

* Home Address State

* Home Address Zip Code

Parent 2

Occupation & Employer

Home Phone

Cell Phone

Name

Email Address

Home Address Street

(If Different)

Home Address City

Home Address State

Home Address Zip Code

Permissions

I hereby give Temple Israel permission for the following information to be shared with other congregational families via a congregational directory.

	Names
	Child(s) Grades
	Home Address
	Home Phone
	Parents' Cell Phone
	Parents' Email Addresses

I hereby give Temple Israel authorization to use photographic, electronic &/or digital images and video of my child(ren) WITHOUT USE OF NAMES in publications, social media, and in public relations materials. Such materials may be used for in-house and media marketing of our school and congregation in newspapers, magazines, and visual media. They are used strictly to promote Temple Israel and our programs; they will not be sold to any publications.

	Yes
	No

Religious School Fees

LATE FEE OF $36/CHILD FOR ALL REGISTRATIONS OF RETURNING STUDENTS RECEIVED AFTER AUGUST 17TH

Kindergarten - Grade 3	$180
Grade 4 - Grade 7	$360

* Child 1 Grade

Child 2 Grade

Child 3 Grade

PAYMENT OPTIONS

To pay in full using Credit Card or Electronic Check (ACH), please refer to the Payment Information section at the bottom of this form. NOTE: A 3% PROCESSING FEE IS ADDED TO ALL CREDIT CARD PAYMENTS

To set up automatic recurring payment installments using a Credit Card or Electronic Check (ACH) please refer to the installment payment question at the bottom of this form.

Emergency Medical

In case of emergency, if parents cannot be reached please notify one of the following:

* Name

* Phone Number

* Relationship to Child(ren)

Name

Phone Number

Relationship to Child(ren)

Medical Personnel Contact Information

* Name of Doctor

* Phone Number

* Name of Dentist

* Phone Number

* Date of child's last tetanus shot

In the event of an emergency, the following information may be necessary in order for your child to receive emergency care at the emergency room of the nearest hospital:

* Insurance Company

* Insured's Name

* Policy Number

* Group Number

Signature

* Typing your signature below indicates that you have provided us with the information noted above and that you are choosing to enroll your child(ren) in our program. We so looking forward to having your family with us!

Please type your name

*Membership at Temple Israel

If you are not currently a Temple Israel member, we look forward to welcoming you and your family into the congregation. Please contact our Temple Administrator, Jennifer Green Baer ([email protected]).

Our membership rates vary depending upon the age of the adults in the family. Families who are joining as their children begin Religious School are gifted with their first year of Temple Israel membership as long as their oldest child is under grade 4.

Temple Israel will not turn away any family due to financial need.

I would like to pay my balance in installments

NOTE THAT A 3% PROCESSING FEE IS ADDED TO ALL CREDIT CARD PAYMENTS

Account Details

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

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Temple Israel Youth Learning Registration 2018 - 2019