Congregation B'nai Israel

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Thank you for registering your child for a youth group at CBI. The options are:

Machar 4th & 5th grades;
Kadima 6th – 8th grades;
USY 9th – 12th grades

Please complete the form below. Dues for each youth group are $36 per year.

Qty

Description

Amount

Total

Youth Group Dues for Machar 4th & 5th grades

$36.00

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Youth Group Dues for Kadima 6th – 8th grades

$36.00

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Youth Group Dues for USY 9th – 12th grades

$36.00

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Total: $0.00

Student Information

Student #1

Student Name: *

Grade: *

Youth Group:

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: *

Parent Cell Phone: *

Parent E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *