PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

Safety is our highest priority and COVID protocols will be enforced in our building by: all wearing masks - vaccinated or unvaccinated; Facility cleanliness - handwashing, hand sanitzier in each classroom; Hepa Air filters running in each classroom Weekly updates clearly communicated in our online eblast.

Family Information

Please fill out completely so we have the most accurate and up to date info for your family.

Parent A

* Full Name

* Cell Phone

* Email

Parent B

Full Name

Cell Phone

PRIMARY MAILING ADDRESS

* Street Address

Apartment or Unit Number

* City

* State

* Zip Code

Does your child split time between two homes? If yes, would you like communication sent to both homes or only to primary? *

Please provide secondary mailing address

Are there additional children in your home that will not be attending Religious School? If so please note name and age for children. This helps us keep accurate Synagogue records and determine age appropriate material

Name and Age of Child NOT attending

Medical and Emergency Contact

It is extremely important that in the event of a true emergency we have all relevant and updated information about your child(ren) to ensure they get the most accurate and quickest medical care possible; please fill out all info below.

Do any of the enrolling students have a health condition that requires medication (please specify if daily); if yes, please note which child, what is the condition and what is the medication required (please note any inhalers or oral medication.)

Do any of the enrolling children have a food or other allergy? If yes, please note which child. IF THIS IS A SEVERE FOOD ALLERGY PLEASE NOTE!

* Preferred Physician/Emergency Treatment Center:

* Emergency Contact (MUST BE OVER 18 AND NOT LISTED AS PARENT OR GUARDIAN):

* Emergency Contact Cell Phone:

DISCLAIMER FOR USE OF IMAGES AND RECORDINGS: I/We hereby give Congregation B'nai Israel permission to photograph, video and audio record during any Religious School event. I also acknowledge that my child(ren)'s image may be used in a variety of media-including, but not limited to; website, printed materials and social media for purposes of marketing Temple B'nail Israel Religious School. I understand that no image or recording of my child(ren) will be sold to any person/organization for any reason.

* I agree to disclaimer for use of Images and Recordings:

	Yes
	No

Payment information

I will pay in full by credit card or check below

Yes

Personal check via mail/drop off

Monthly ACH withdrawal

I am requesting need based scholarship.

We appreciate your registration and look forward to welcoming you on our Opening Day Sunday August 29, 2021 at 9:00 am!

Account Details

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

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total:

	Team K/1 (Grades Kindergarten and 1st)
	Team 2/3 (Grades 2nd and 3rd)
	Team 4/5/6 (Grades 4th, 5th, 6th)
	Team 7/8 (Grades 7th and 8th)
	Team 9/10 (Grades 9th and 10th)

	Team K/1 (Grades Kindergarten and 1st)
	Team 2/3 (Grades 2nd and 3rd)
	Team 4/5/6 (Grades 4th, 5th, 6th)
	Team 7/8 (Grades 7th and 8th)
	Team 9/10 (Grades 9th and 10th)

	Team K/1 (Grades Kindergarten and 1st)
	Team 2/3 (Grades 2nd and 3rd)
	Team 4/5/6 (Grades 4th, 5th, 6th)
	Team 7/8 (Grades 7th and 8th)
	Team 9/10 (Grades 9th and 10th)

	Provide Snack items - indiv. wrapped and juice boxes
	Opening Day activities
	Sukkot - celebration/meal
	Hanukkah - family celebration
	Purim - carnival
	Pesach - Seder, other
	Little Lafty
	Middle Lafty
	Lafty
	End of school/Closing Event
	Teacher Appreciation
	Substitute Teacher/helper