Congregation B'nai Israel

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Thank you for registering for or refilling your child(ren)’s Youth Snack Payment Card for snacks during Wednesday SHMA Religious School at Congregation B’nai Israel. Please complete all requested information below & $15 will be added to your child’s card.

Qty

Description

Amount

Total

New/Add $15 to card

$15.00

---

Total: $0.00

Student Information

Student #1

Student Name: *

Grade: *

Allergies: *

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *