PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

Yahrzeits

Name of Deceased

Relationship

Date of Death

Name of Deceased

Relationship

Date of Death

Name of Deceased

Relationship

Date of Death

Name of Deceased

Relationship

Date of Death

Name of Deceased

Relationship

Date of Death

Children Information

Child 1

Full Name

First Name, Last Name

Gender

Mailing Address

If not living with Parent(s)

Birth date

Hebrew Name

Bar/Bat Mitzvah Date

Read and/or chant Hebrew?

Confirmation Date

Name of School

Grade

Hebrew School Grade

Religious School Grade

Attend Jewish Camp? Name of Camp?

Physician Name

Phone

Allergies?

Other pertinent medical information

Interested in Junior or Senior Youth Group?

	Yes
	No

Child 2

Full Name

First Name, Last Name

Gender

Mailing Address

If not living with Parent(s)

Birth date

Hebrew Name

Bar/Bat Mitzvah Date

Read and/or chant Hebrew?

Confirmation Date

Name of School

Grade

Hebrew School Grade

Religious School Grade

Attend Jewish Camp? Name of Camp?

Physician Name

Phone

Allergies?

Other pertinent medical information

Interested in Junior or Senior Youth Group?

	Yes
	No

Child 3

Full Name

First Name, Last Name

Gender

Mailing Address

If not living with Parent(s)

Birth Date

Hebrew Name

Bar/Bat Mitzvah Date

Read and/or chant Hebrew?

Confirmation Date

Name of School

Grade

Hebrew School Grade

Religious School Grade

Attend Jewish Camp? Name of Camp?

Physician Name

Phone

Allergies?

Other pertinent medical information

Interested in Youth Group?

	Yes
	No

Membership Classification

**If you are need of dues relief, please still select the membership classification that applies to your household and check the Dues Adjustment box below.**

Classification

	Couple (two adult household)	$2,845.00
	Senior Couple (one person 65 or older)	$2,130.00
	Single (one adult household)	$1,450.00
	Senior Single (65 or older)	$1,100.00
	Young single adult (under 30)	$395.00
	Associate (member of another temple or child enrolled in a Jewish Day School or Preschool)	$860.00

Our Annual Security Assessment is for the safety and well-being of our community and its members.

* Security Assessment

Annually

$215.00

*New members also pay a Building Maintenance Assessment of $300 annually for 3 years; all other members pay an Annual Maintenance Repair Fund charge of between $75 and $205 per year.

* Building Maintenance Assessment

Member 1 - 3 years

$300.00

Additional Donation $

Will you pay by check?

Please make check payable to TEMPLE SINAI OF GLENDALE totaling the amount in the parenthesis above.

Dues Adjustment

Temple Sinai does not deny membership to anyone due to financial hardship. A financial “hardship” does not have to be a catastrophic event. If for any reason you feel you require dues adjustment, please check here and our Financial Secretary will contact you for a confidential conversation.

I would like to be contacted by the Financial Secretary

I would like to pay the balance in installments with the first transaction processed today.

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 2.5% to cover credit card fees. Please select YES to increase your payment.

Total:

	Orthodox
	Conservative
	Reform
	Secular

	Adult Education
	Board of Directors
	Brotherhood
	Sisterhood
	Social Action
	Transportation Assistance
	Landscaping/Gardening
	Choir
	Library
	Fund Raising
	Senior Adults
	Mah Jongg
	20's and 30's Group
	Caring Community
	Legal
	Mailings
	Computer
	Community Relations
	Clerical Help
	Sound Systems
	Photography
	Handy-Person
	Other

	Orthodox
	Conservative
	Reform
	Secular

	Adult Education
	Board of Directors
	Brotherhood
	Sisterhood
	Social Action
	Transportation Assistance
	Landscaping/Gardining
	Choir
	Library
	Fund Raising
	Senior Adults
	Mah Jongg
	20's and 30's Group
	Caring Community
	Legal
	Mailings
	Computer
	Community Relations
	Clerical Help
	Sound Systems
	Photography
	Handy-Person
	Other

Membership Application 2018-2019