Caregiver & Child Classes December & January Registration
CHILD'S INFORMATION
First Name
Middle Name
Last Name
Prefers to be called
Date of Birth
SESSION REGISTRATION
Are you a WHC member?
Yes
No
I'd like to register my child for the following sessions of this program:
December 4, 11, & 18, 2024
January 8, 15, 22 & 29, 2025
Both the December & January sessions
I'd like to register my child for the following sessions of this program:
December 4, 11, & 18, 2024
January 8, 15, 22 & 29, 2025
Both the December & January sessions
Child will be attending with (Check all that apply)
Parent/Guardian 1
Parent/Guardian 2
Additional Caregiver(s)
FAMILY INFORMATION
PARENT / GUARDIAN 1
First Name
Last Name
Email Address
Phone Number
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code
PARENT / GUARDIAN 2
First Name
Last Name
Email Address
Phone Number
Is there an additional address you would like to provide for this parent?
Yes
No
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code
OTHER CAREGIVERS
First Name
Last Name
Email Address
Phone Number
Relationship to Child
ADDITIONAL INFO
Do you need any accommodations to allow full participation in this classs?
Yes
No
What accommodations do you need?
Snack will be served as part of this program. Does your child have any allergies?
Yes
No
Please explain the allergies here:
If there's anything else you'd like us to know about your child, please use the space below:
How did you hear about this program? Check all that apply.
Digital ad
ECC/WHC
family
Print ad
Shalom TV
Social media
WHC newsletter
WHC website
Other
Which family?
TOTAL COST
Subtotal (formSubtotal)
$
Admin Code (Staff Use Only)
Please select...
No
Yes
Enter Admin Code
Amount Due Today (DiscountTotal)
$
Would you like to make a donation? Enter the amount below. Donations to the Lewis S. Wiener Annual Fund support the Temple's greatest financial need.
$
This donation is from:
Total Amount (TotalAmount)
$
Refund policy
PAYMENT METHOD
How would you like to pay your bill?
Credit Card (includes 3% fee)
ACH (Direct Bank Debit - No fee)
CREDIT CARD INFORMATION
To help defray some of WHC's credit card processing costs, a 3% fee has been added to your credit card payment. Please note that ACH payments do not include this fee.
Fee Amount
$
Grand Total
$
First Name on Card
Last Name on Card
Credit Card Number
Expiration Month
Please select...
01
02
03
04
05
06
07
08
09
10
11
12
Expiration Year
Please select...
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
CVV
Billing Street
Billing City
Billing State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Billing Zip Code
ACH INFORMATION
Bank Routing Number
Bank Account Number
Bank Account Type
Checking
Savings
Bank Name
Account Holder's Name (
NOTE: If this is a joint account, use one name only. If it's a trust/foundation use one first/last name only
)
Billing Street
Billing City
Billing State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Billing Zip Code
Publicly Hidden Fields
Payment Section
Hide Payment Info
Hidden
Portal Pre-Fill Fields
Account ID
Contact ID
Outreach/Event Pre-Fill
OutreachID
DesignationID
Auth.net Connector Billing Info
Gateway Address
Gateway City
Gateway State
Gateway Zip
Gateway Totals
Gateway Quantity
Gateway Amount
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