Religious School Registration Form

Family Information
Name of Parent or Guardian #1*
First Last
Name of Parent or Guardian #2
First Last
Family Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian #1 Email*
#1 Home Phone*
#1 Work Phone
#1 Cell Phone
Parent/Guardian #2 Email
#2 Home Phone
#2 Work Phone
#2 Cell Phone
Please send email correspondence to:*
- Parent/Guardian #1 Email
- Parent/Guardian #2 Email

Insurance Information
Insurance Plan Information*
Medical Insurance*
Permission for Medical Treatment
I hereby give permission for the synagogue to secure all necessary treatment for the safety and health of my child. I understand that my child will be taken to the nearest hospital or appropriate medical facility as indicated by the emergency. I understand that in case of emergency, every effort will be made to reach me or my designated emergency contact.
Signature*

Code of Conduct
Click Here to read the Kesher Israel Congregation Religious School Student Code of Conduct
We have read and acknowledge the Kesher Israel Congregation Religious School Student Code of Conduct*
- Yes
Parent Signature*
Student #1 Signature*
Student #2 Signature
Student #3 Signature

Payment Information
Which method will you use to pay Religious School Tuition?*
A 3% convenience fee will be added to all Credit Card and Paypal transactions
- Check to Kesher Israel Congregation
- Credit Card
- Paypal
- Direct Debit from Checking Account
3% Convenience fee for Credit Card and Paypal payments
Price: $0.00
10% discount for families with 3 or more students*
Price: $0.00
Total
$0.00
Billing Name*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Email*
Billing Phone*
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Direct Debit
Please fill out an ACH form for Direct Debit and send to joycebh@verizon.net or mail to Kesher Israel Congregation
Email

Family Information