Registration

$125 registration fee to reserve your child’s space
will be charged at the time of registration.

Mother's Information

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Home Phone: *

Cell Phone:

Email: *

Work Phone:

Employeer:

Address:

City:

State:

Zip:

Father's Information

First Name: *

Last Name: *

Same as Mother's Address

Address: *

City: *

State: *

Zip: *

Home Phone: *

Work Phone:

Cell Phone:

Email: *

Permission

I give Temple Tot’s permission to use my child’s picture in newspapers, magazines, publicity brochure, our internet website, or other media forms.
Yes No

Emergency Contacts

Name: *

Relation: *

Home Phone: *

Cell/Work Phone: *

Name: *

Relation: *

Home Phone: *

Cell/Work Phone: *

	Tuition
Are you a member? Member Non-Member Your banking and credit card information is kept secure using SSL 256-bit encryption. Automatic Funds Transfer Payments I authorize Temple Emanu-El to perform an automatic funds transfer on the 1st of each month from my checking account to fulfill my child’s Temple Tots preschool tuition. Charges will be based on the number of days I have committed my child to attend. If my automatic funds transfer payment fails to process due to insufficient funds or for any other reason, I authorize Temple Emanu-El to collect a $25 fee by electronic charge to my checking account identified below. Please enter your checking account number.

Name on Account:

Same as Mother's Address Same as Father's Address

Address:

City:

State:

Zip:

Phone:

Routing Number:

Checking Account No.:

By check this box you are authorizing Temple Emanu-El to perform an automatic transfer as stated above.

Credit Card Payments

I authorize Temple Emanu-El to charge my credit card on the 1st of each month to fulfill my child’s Temple Tots preschool tuition. Charges will be based on the number of days I have committed my child to attend. If my credit card payment fails to process due to insufficient funds or for any other reason, I authorize Temple Emanu-El to collect a $25 fee by electronic charge.

Credit Card Type: MasterCard VISA American Express Discover Card

Name on Card:
(Exactly as it appears on card)

Credit Card No.:

Same as Mother's Address Same as Father's Address

Credit Card Billing Address:

City:

State:

Zip:

Phone:

By check this box you are authorizing Temple Emanu-El to charge my credit card as stated above.