2017-2018BETH SHIR SHALOM JELLI/YOUTH GROUP REGISTRATION AND PAYMENT AGREEMENT

Student’s Last Name______Student’s First Name ______Date of Birth ______

Student’s Hebrew Name ______Student’s E-Mail ______

Parent #1 Last Name______First Name______E-Mail ______

HomeAddress______City______State_____ Zip Code ______

Home Phone ( ) ______Work Phone ( ) ______Cell Phone ( ) ______

Parent #2 Last Name______First Name______E-Mail ______

HomeAddress______City______State_____ Zip Code ______

Home Phone ( ) ______Work Phone ( ) ______Cell Phone ( ) ______

Student resides with: Mother_____Father____ Step Parent ____ Both Parents____Marital Status of Parent(s)______

Please check schedule for your child: Note – All classes pay a $60 Books and Materials fee and Kindergarten

Through 6th Grade pay a $50 Snack and Purim Sponsorship fee

Kindergarten 1st Grade  2nd Grade(Sundays from 9:00 a.m.-12:00 noon)

Members Tuition:$800 + $60+ $50

3rd Grade 4th Grade 5th Grade6th Grade (Sundays from 9:00 a.m.-12:00 noon, Optional: Tuesdays Hebrew Enrichment from 4:00 – 6:00 p.m.) Tuition:$1,200 + $60 + $50

Club 78 (7th & 8th Grade)–(Tuesdays from 5:45 - 7:45 p.m.)

7th Grade8th Grade Tuition:$720 + $60

Youth Group- BeSHTY/NFTY 1 weekend activity per month

9th Grade10th Grade 11th Grade 12th GradeTuition:$360 + $60

Bar/Bat Mitzvah Training Fee  - $2,000(Training will begin once Fee is paid in Full)

2017-2018BETH SHIR SHALOM DUES AGREEMENT

The Board has set the minimum annual dues contributions as follows:

$2,850/yr. for Family Membership

My/Our Annual Dues Pledge for 2017-2018 is: $ ______

Special Circumstances: We aspire to make Temple membership attainable for all who wish to join. A variety of membership options and payment plans are available. Please contact Temple Administrator, Cynthia Barzilai for more information.

PAYMENT OPTIONS (check one)

OPTION 1:______Pay in full by August 31, 2017 directly to Beth Shir Shalom

OPTION 2:______10 Monthly payments via Bank Auto Pay, Check or Credit Card*from 8/1/17through 5/1/18

CASH  CHECK  CHECK# ______CREDIT CARD *

Visa or Master Card # ______

Expiration Date: ___/___Security Code (on back of card) ____ Name as it appears on card ______

Credit Card Authorization Signature ______Date______

* A 3% Convenience Fee will be added to your tuition and dues amount for credit card payments.

I hereby agree to pay my child’s tuition and membership dues as specified above. If tuition is not paid in full by May 5, 2018, I understand that my child may be excluded from attending the Beth Shir Shalom JELLI School. Should legal collection become necessary, I agree to pay all reasonable attorney, court and other costs incurredin collecting such fees.

Signature of Person Responsible for Payment______Date______