PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

Please register your student(s) in grades K - 12 for the 2021-2022 Kesher school year, below.

Student 1

* First Name

* Last Name

* Gender

* Grade

Medical Conditions / Allergies

If not applicable, please indicate N/A

Does your child take any medications?

Medications

If your child does take any medications, please describe the medication and what it is used for.

Please provide the name of one other student you would like your child to be in class with.

Student 2

First Name

Last Name

Gender

Grade

Medical Conditions / Allergies

If not applicable, please indicate N/A

Does your child take any medications?

Medications

If your child does take any medications, please describe the medication and what it is used for.

Please provide the name of one other student you would like your child to be in class with.

Student 3

First Name

Last Name

Grade

Gender

Medical Conditions / Allergies

If not applicable, please indicate N/A

Does your child take any medications?

Medications

If your child does take any medications, please describe the medication and what it is used for.

Please provide the name of one other student you would like your child to be in class with.

Student 4

First Name

Last Name

Gender

Grade

Medical Conditions / Allergies

If not applicable, please indicate N/A

Does your child take any medications?

Medications

If your child does take any medications, please describe the medication and what it is used for.

Please provide the name of one other student you would like your child to be in class with.

Parent/Guardian Information

Parent/Guardian 1

* Full Name

* Cell Phone

* Email

Parent/Guardian 2

Full Name

Cell Phone

If parents are not living together, it is our practice to communicate with both parents unless a different arrangement is requested in writing.

Student(s) live with

Medical Release

Temple Israel agrees to take reasonable measures for the protection of the health of each child. However, it assumes no risk for injuries, accidents and/or sickness incurred or received by any child whether directly or indirectly while attending school, school trips and youth group events or under faculty supervision. I agree to release and hold harmless Temple Israel, its trustees and employees from any and all claims that may arise as a result of any injury, loss or damages incurred by me or my family. In the event of any medical emergency or accident, the Temple Israel Religious School or Youth Program staff reserves the right to move your child to an appropriate hospital. I hereby authorize such physicians or emergency facility to treat my child in any emergency situation until such time as I can be reached for specific permission.

* Signature

By signing here, I agree to the terms and conditions listed above regarding responsibility and emergency medical procedures.

* Date (month/day/year)

Media Release

Temple Israel has my permission to use any photos or videos of Kesher or youth group activities in which my child may appear in the representation of its school and youth programs to the community.

* Media Release

	Yes
	No

Payment

Kindergarten - Free

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11 & 12

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

I would like to help offset Temple Israel's credit card processing fee with an additional 2.5% contribution.

Total: