Circles of Connection
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Outreach ID
Outreach Name
Outreach Display Name
Hit Capacity
Yes
No
Designation Name
Designation ID
Payment model
Please select...
Free
Per Person
Per Ticket Charge
Optional Donation Box
Yes
No
Sponsor Others Allowed
Yes
No
Financial Assistance Box
Yes
No
Pay On Form
Yes
No
Check in Advance
Yes
No
Pay at the Door
Yes
No
Number of Payment Methods
Immediate Payment Structure
Please select...
Credit card only - no fee
Credit card only - 2% fee
ACH only - no fee
Credit card or ACH - no fee
Credit card with 2% fee, ACH no fee
Dietary Question Format
Please select...
Open-ended
Specific
Dietary Restrictions
Please select...
Vegetarian
Vegan
Gluten free
Dairy free
Tree nuts
Peanuts
Other
Hybrid Registration
Yes
No
Event advertising copy goes here
Your First Name
Your Last Name
Your Email Address
Please indicate which session or sessions you plan to attend:
Thursday, May 1, 12:00-1:30 PM
Wednesday, May 14, 12:00-1:30 PM
Wednesday, May 28, 7:15-8:45 PM
Attending:
In-person
Online
Do you have any dietary restrictions? Check all that apply.
Vegetarian
Vegan
Gluten free
Dairy free
Tree nut allergy
Peanut allergy
Other
Please describe:
Do you have any dietary restrictions we should be aware of? Please describe.
If you are experiencing financial hardship and would like to request assistance for the cost of this event, please indicate:
Yes, I would like to request financial assistance
No, thank you
Would you like to make a donation?
Yes!
No, thank you
Your donation of $18 or more helps fund meaningful TBS programs throughout the year. Thank you so much!
Donation Amount
$
How would you like your name to appear for acknowledgement?
E.g. "The Smith Family", "John & Jane Smith", etc
Would you like to sponsor another participant who is experiencing financial hardship?
Yes!
No, thank you
Sponsorship
Cost to sponsor one participant
$
How many participants would you like to sponsor?
Total sponsorship - thank you!
$
Payment
Ticket
$
Donation
$
Sponsorship
$
Total
$
How would you like to pay?
Pay now by providing payment details
Pay by check in advance
Pay at the door
How would you like to pay?
Pay now by providing payment details
Pay by check in advance
How would you like to pay?
Pay now by providing payment details
Pay at the door
How would you like to pay?
Pay by check in advance
Pay at the door
Payment options
Pay by credit card (2% fee)
Pay by eCheck/ACH
Payment options
Pay by credit card
Pay by eCheck/ACH
Credit Card Payment Information
2% Credit Card Fee
$
Total with Fee
$
First Name on Card
Last Name on Card
Credit Card Number
Security Code
CVV
x
Expiration Month
MM
Expiration Year
YYYY
Billing Street
Billing City
Billing State
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AL
AK
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CA
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CT
DE
FL
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IN
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Billing Zip Code
eCheck Payment Information
Account Holder Name
Only enter one name (e.g. John Smith, not John and Jane Smith)
Bank Routing Number
Bank Account Number
Bank Account Type
Please select...
Checking
Savings
Bank Name
Pay By Check in Advance
Checks should be made out to Temple Beth Shalom, 670 Highland Ave, Needham, MA 02494. Please include the name of the event in the memo line.
Please be sure to bring your payment in the amount above with you to the event!
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Please select at least one session above.
Contact Information