PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

The parent/guardian contact information below will also be used for our RAVE Emergency Notification System, which enables Temple Israel Religious School to contact you in the event of an emergency or safety concern via text, phone, and email.

Parent/Guardian Contact #1

* First and Last Name

* Address

Please include city, state, and zip.

* Phone #1

Primary contact number.

* Type

Cell
Work
Home

Phone #2

Secondary contact number.

Type

Cell
Work
Home

Email Address

Primary email address in which you'd like to be contacted in case of emergency.

Occupation

Parent/Guardian Contact #2

First and Last Name

Address

Please include city, state, and zip.

Phone #1

Primary contact number.

Type

Cell
Work
Home

Phone #2

Secondary contact number.

Type

Cell
Work
Home

Email Address

Primary email address in which you'd like to be contacted in case of emergency.

Occupation

Please complete this section if parents are divorced/separated

Child lives with:

Parent #1
Parent #2
Both
Other

Please explain any shared custody arrangements that may affect your student's well-being or attendance at school:

Emergency Contact (in addition to parents/guardians)

Emergency Contact Name

Phone Number

Relationship to Student

Waiver and Permissions: REQUIRED

Medical: In the event of a medical emergency, I authorize the staff to administer first aid and/or obtain emergency medical treatment for my child. I understand that an attempt will be made to contact me immediately. If injury is serious and parents cannot be contacted, my child will be brought by ambulance to the nearest hospital. Costs of the medical attention and ambulance are the responsibility of parent/guardian.

* Please check the box below:

I understand and agree to the terms above

Emergency Authorization It is understood and agreed that Temple Israel, its agents, and employees shall not be liable for any claims, actions, or causes of action arising out of any conduct authorized here, and the undersigned hereby specifically releases Temple Israel and its agents, designees, and employees from any and all such claims, actions, or causes of action.

* Please check the box below:

I understand and agree to the terms above

Publicity Here at TI, we work hard to build community â in our classrooms, in our hallways, and in everything that we do. Our DECC and Religious school want to share all the wonderful things that our students do here with you, and that sharing includes lots of pictures - on our walls, in our classrooms, in our newsletters, and other media sources. We will not list student names with pictures. We also publish an in-school directory by class with student names and phone numbers. If you have any concerns or questions about this, please contact us at 314-432-8076.

* Please check the box below:

I understand and agree to the terms above

MEMBERS - Student Grade(s) & Fee(s)

Student #1

	Wednesday with Miss Lisa	$0.00
	Thursday with Miss Jane	$105.00
	Tadpoles/Froggie (2 Days)	$220.00
	Froggies/Bumblebees (3 Days)	$315.00
	Froggies/Bumblebees (4 Days)	$410.00
	Froggies/Bumblebees (5 Days)	$505.00
	Dolphins	$505.00
	Lizards 9:00am - 1:15pm	$665.00

Student #2

	Wednesday with Miss Lisa	$0.00
	Thursday with Miss Jane	$105.00
	Tadpoles/Froggie (2 Days)	$220.00
	Froggies/Bumblebees (3 Days)	$315.00
	Froggies/Bumblebees (4 Days)	$410.00
	Froggies/Bumblebees (5 Days)	$505.00
	Dolphins	$505.00
	Lizards 9:00am - 1:15pm	$665.00

Student #3

	Wednesday with Miss Lisa	$0.00
	Thursday with Miss Jane	$105.00
	Tadpoles/Froggie (2 Days)	$220.00
	Froggies/Bumblebees (3 Days)	$315.00
	Froggies/Bumblebees (4 Days)	$410.00
	Froggies/Bumblebees (5 Days)	$505.00
	Dolphins	$505.00
	Lizards 9:00am - 1:15pm	$665.00

OTHER PROGRAMS OFFERED AT DECC
Please call the main office to make arragements
Pre and Post Care	(Payment is by the month and cost is $10 per hour)
Lunch Brunch 12:00 - 1:15pm	(Payment is by the month and cost is $10 per day)
Extended Days 1:15 - 3:15pm	(Payment is by the month and cost is $20 per day)

NON-MEMBERS - Student Grade(s) & Fee(s)

Student #1

	Wednesday with Miss Lisa	$0.00
	Thursday with Miss Jane	$130.00
	Tadpoles/Froggie (2 Days)	$265.00
	Froggies/Bumblebees (3 Days)	$390.00
	Froggies/Bumblebees (4 Days)	$485.00
	Froggies/Bumblebees (5 Days)	$610.00
	Dolphins	$610.00
	Lizards 9:00am - 1:15pm	$745.00

Student #2

	Wednesday with Miss Lisa	$0.00
	Thursday with Miss Jane	$130.00
	Tadpoles/Froggie (2 Days)	$265.00
	Froggies/Bumblebees (3 Days)	$390.00
	Froggies/Bumblebees (4 Days)	$485.00
	Froggies/Bumblebees (5 Days)	$610.00
	Dolphins	$610.00
	Lizards 9:00am - 1:15pm	$745.00

Student #3

	Wednesday with Miss Lisa	$0.00
	Thursday with Miss Jane	$130.00
	Tadpoles/Froggie (2 Days)	$265.00
	Froggies/Bumblebees (3 Days)	$390.00
	Froggies/Bumblebees (4 Days)	$485.00
	Froggies/Bumblebees (5 Days)	$610.00
	Dolphins	$610.00
	Lizards 9:00am - 1:15pm	$745.00

OTHER PROGRAMS OFFERED AT DECC
Please call the main office to make arragements
Pre and Post Care	(Payment is by the month and cost is $10 per hour)
Lunch Brunch 12:00 - 1:15pm	(Payment is by the month and cost is $10 per day)
Extended Days 1:15 - 3:15pm	(Payment is by the month and cost is $20 per day)

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

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total:

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	Wednesday
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	Friday

	Monday
	Tuesday
	Wednesday
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	Friday

	Monday
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Deutsch Early Childhood Center
Registration Form: 2016-17