Religious School Registration

Parent 1's Information

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Home Phone:

Work Phone:

Cell Phone:

Email: *

Occupation:

Parent 2's Information

First Name:

Last Name:

Same as Parent 1's Address

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

Occupation:

Emergency Contacts

Name: *

Relation: *

Home Phone:

Cell/Work Phone: *

Email:

Name: *

Relation: *

Home Phone:

Cell/Work Phone: *

Email:

Parents, please chose one of the following to enhance your child’s Religious School experience.

Holiday Programming
Fundraising for summer Jewish experiences including Jewish Camps, Study in Israel
Social events for kids and parents

Are you interested in being one of our fabulous teachers?

1. Hebrew School: Yes
If Yes enter name(s) below

Name:

2. Religious School: Yes
If Yes enter name(s) below

Name:

Permissions

I hereby grant and assign Temple Emanu-El the irrevocable and unrestricted right to use and publish for editorial trade, advertising or any other purpose and in any manner and medium including website and internet promotion, all photographic, video, and digital images:
Yes No

I affirm that I understand the instructions as listed on this form and that all information I have provided is valid and complete.

Payment

Your banking and credit card information is kept secure using SSL 256-bit encryption.

Kindergarten-3rd	Member $458.00	Non-Member $505.00
4th-6th	Member $683.00	Non-Member $750.00
TEEN’s 7th & 8th	Member $643.00	Non-Member $710.00
Confirmation 9th & 10th	Member $643.00	Non-Member $710.00

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 Religious School tuition. 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 Parent 1's Address Same as Parent 2'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 Religious School tuition. 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.:

CCV:

Same as Parent 1's Address Same as Parent 2's Address

Credit Card Billing Address:

City:

State:

Zip:

Phone:

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

Pay in FULL by August 31st.
Send payment to:
Temple Emanu-El
Attn: Anita Winslett
2100 Highland Avenue
Birmingham, Alabama 35205
anita@ourtemple.org
Office: 205-933-8037, ext. 230