Congregation B'nai Israel

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

SHMA@cbirumson: Soul Heart Mind Academy

Grade	Tuition	Registration Fee	Materials Fee	Total
Pre-K (once a month)	Free	Waived	None	Free
K-1 Members or Gan Alumni	Free	Waived	$85	$85
K-1 Non-members	$710	$200	$85	$995
2-7 (Membership Req'd)	$725	$200	$85	$1010
8-12 Members	$255	$200	$180*	$635
8-12 Non-members	$710	$200	$180*	$1090

*covers additional expenses for Hebrew HS activities.

Instructions:

Please choose EITHER OPTION 1 or OPTION 2.

OPTION 1
Full Payment

**INCLUDES registration/materials fee:

Qty

Description

Amount

Total

Pre-K Free (No registration fee)

$0.00

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K-1 Member/Gan Alumnus Registration Fee

$85.00

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K-1 Non-Member Full Payment

$995.00

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Grade 2-7 Member Full Payment

$1,010.00

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Grade 8-12 Member Full Payment

$635.00

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Grade 8-12 Non-Member Full Payment

$1,090.00

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Congregation B'nai Israel pays a processing fee for this financial transaction. To help defray the cost of this fee, you may add 3% to your payment. If you would like to do this, please check here.

-OR-

Option 2
Registration/Materials Fees By Grade

** Please note you will be billed for remainder of fee, if any. To arrange installment payments for remainder, please contact Alice MacPhee, CBI Bookkeeper, at 732-842-1800 x211 or bookkeeper@cbirumson.org.

Qty

Description

Amount

Total

K-1 Non-Member Rate Registration/Materials Fee

$285.00

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Grades 2 – 7 (membership required) Registration/Materials Fee

$285.00

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Grades 8 - 12 (Member Rate) Registration/Materials Fee

$380.00

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Grades 8 - 12 (Non-Member rate) Registration/Materials Fee

$380.00

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Child(ren) Information

Child #1 Name: *

Hebrew Name: *

Gender: *

Date of Birth (mm/dd/yyyy): *

Current Grade in Secular School: *

Current Grade in CBI Religious School: *

Special Accommodations Needed: *

Please specify Special Accommodations Needed: *

Please Specify Medications: *

Physician's Name: *

Physician's Phone: *

Waivers

Activities Waiver
I hereby give permission for my child/children to participate in all activities sponsored by Congregation B’nai Israel Religious School, including all announced trips. In case of an emergency, I realize that Congregation B’nai Israel Religious School will make every effort to contact my designate or me. In the event that no one can be reached, I authorize CBI to seek medical assistance for my child with an appropriate physician.

Activities Waiver: *

Photo Waiver
I hereby give permission for my child/children to be photographed in the course of activities at Congregation B’nai Israel Religious School with the understanding that these photographs may be used for promotional and advertising purposes.

Photo Waiver: *

Family Information

Parent 1 Name: *

Street Address: *

City, Zip: *

Home Phone: *

Cell Phone: *

Parent 1 Email: *

Occupation:

Parent 2 Name:

Street Address:

City, Zip:

Home Phone:

Cell Phone:

Parent 2 Email: *

Occupation:

Report Card/School Mailings should be sent to: *

I Am Interested In Serving In One Of These Roles: *

Who transports your child to and from CBI?

Name: *

Telephone: *

Relationship: *

In Case Of Emergency
(when we are unable to reach parents at above numbers)

Name: *

Relationship To Child: *

Phone #: *

Cell #: *

Hospital Preference:

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: *