KEHILLA MEMBERSHIP and SCHOOL REGISTRATION FORM | 2017-2018

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Welcome to the Kehilla Membership and School Registration Form

You may use this form to become a member, renew your membership, and/or register children for Kehilla School. If you have questions or need assistance, please contact Dee at Dee@kehillasynagogue.org

IF YOU HAVE ANY ISSUES, SAVE THE FORM FIRST BY CHECKING THE BOX AT THE TOP, AND THEN CONTACT DEE.

To get into the form, you will need to enter your DATA-HUB ID.  This is a new ID for all form users and was emailed to all 2016-2017 Members and School Families.  Please check your email.  If you do not have your ID please contact Dee. 


Copying and Pasting it prevents errors
STOP
RETURNING MEMBERS --- Please contact Dee at Dee@kehillasynagogue.org to get your ID.
BRAND NEW? If you are a brand new joining member or family, you may create an ID here.  This is ONLY for brand new households who are not in our database.  Thank you.

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Adult and Household Info
Please begin with your primary household address






Contact Information - Adult



Email addresses shall only be used for one person





mm/dd/yyyy

Sharing your preferred pronouns helps Kehilla to be inclusive and welcoming to people of all gender identities




Use your keyboard settings to select more than one. Usually this is CTRL+CLICK or COMMAND+CLICK

Click the link ABOVE and to THE RIGHT to add information for another adult in your household. Please include information for EACH adult in every household.


Siblings



mm/dd/yyyy

Children in My Household



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Additional Household
Adult Contact Info








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Student Enrollment Information



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PLEASE NOTE: Most Kehilla School families are Kehilla Members.  All 6th grade families must be members. You can add membership to your enrollment in the next section.   Also, there will be a $250 retreat fee added for all 6th graders.  This is will be in your total.





Click the link ABOVE and to THE RIGHT to enroll another student

School Registration

If you are new to Kehilla School this year, we encourage you to become a member of Kehilla at our reduced first-year membership rate of $180 for single-income households and $360 for two-income households.  Note that 6th grade families must be Kehilla members.
**Only available through 5th grade.
We encourage all Kehilla School families to be Kehilla members.  If you are new to Kehilla School this year, you can become a member at our reduced first-year membership rate of $180 for single-income households and $360 for two-income households. Please note that all 6th grade families must be Kehilla members.Click here to enter text
New Families Membership Cost


$
.00
This will be added to your total

School Tuition Cost - Kehilla Member
Kehilla School tuition is on a sliding scale of $1175-$875. Please consider paying in the middle or at the top of the scale if you can. The range listed below is calculated by $1175-$875 x Kehilla School Student Count above

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$
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Non-member Kehilla School Cost
Tuition for non-members is calculated by  $1,500 X Kehilla School Count above

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.00

$
.00

$
.00

$
.00

$
.00
Joyfully Jewish
Joyfully Jewish for your Kindergarten Student

$
.00

$
.00

We encourage all families to participate in Parent Service.  If it is not possible for your family you may opt to buy out. More Information Here
Parent Service 
Please choose 1 first choice and 1 second choice.
Click here to read about Service Options
First Choice Second Choice

$
.00

$
.00
Tuition Assistance
If you would like to request financial assistance, please pause and save this form by clicking “Save my progress and resume later” at either the top or bottom of this page.  Complete this short request form.  Once you receive a response to your request, you can come back and complete this registration form.  Use the field below to enter the amount of tuition assistance you have been awarded.

I have completed a financial assistance request, and have been awarded this amount of tuition assistance: $
.00
TOTAL SCHOOL ENROLLMENT DUE
The total school enrollment due calculates as follows: {tuition -  tuition assistance - sibling discount - early bird} + {service hours buy-out + Joyfully Jewish + 6th grade retreat} + {donation}
Some fields are optional or not relevant for all families and they will not be included in your total.
The total school enrollment due calculates as follows: {tuition -  tuition assistance - sibling discount - early bird} + {service hours buy-out + Joyfully Jewish + 6th grade retreat} + {donation}
Some fields are optional or not relevant for all families and they will not be included in your total.
The total school enrollment due calculates as follows: {tuition - tuition assistance - sibling discount - early bird} + {service hours buy-out + membership} + {Joyfully Jewish + 6th grade retreat} + {donation}.
Some fields are optional or not relevant for all families and they will not be included in your total.
The total school enrollment due calculates as follows:  {tuition} + {service hours buy-out  +Joyfully Jewish} + {donation}
Some fields are optional or not relevant for all families and they will not be included in your total.

$
.00
Membership
Renew and Rejoin
Recognizing that members have varying financial resources, we have set up our sliding scale fees based on income and household situation.  Please select the appropriate choice below and give as generously as you are able.

Membership Pledge - Individual/One Income – Under 30 years of age
$200 - $600*
Membership Pledge - Individual/One Income – Between the ages of 30-39
$600 - $2,200*
Membership Pledge - Individual/One Income – Between the ages of 40-64
$1,600 - $5,000*
Membership Pledge - Individual/One Income – 65 and over
$500 - $5,000*
Membership Pledge - Two Income – Under 30 years of age
$400 - $900*
Membership Pledge - Two Income – Between the ages of 30-39
$900 - $3000*
Membership Pledge - Two Income – Between the ages of 40-64
$1,800 - $6,000*
Membership Pledge - Two Income – 65 and over
$800 - $6,000*

Using the sliding scale above, please enter your membership pledge in this box.


$
.00

$
.00
Multiply number of youth X amount you'd like to pay and enter the total in this box.

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.00
Enter number of adults in your household and multiply X 100. Enter the total here.
Join Kehilla
We are delighted that you are interested in joining Kehilla! We have special first year member rates.  If you purchased 2017 Kehilla High Holy Day tickets, you may subtract that amount from your dues pledge.  Please select the appropriate choice below. 


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Total 2017-2018 Membership Pledge

The total pledge amount calculates as follows: {your pledge + youth add-on (optional) + Avodah buy-out (optional)}. Not all fields are relevant for all members and will not be included in the calculation if that is the case.

$
.00
*Kehilla Synagogue is committed to making membership accessible to all regardless of financial resource. If you are unable to pay within our sliding scale dues structure,  we can work out an alternative dues arrangement.  

Please pause and save this form by clicking “Save my progress and resume later” at either the top or bottom of this page.  Then contact Executive Director Michael Saxe-Taller (510-547-2424 x101, Michael@kehillasynagogue.org) to have a confidential conversation.  Once an arrangement has been made, you can come back and complete this registration form. 

PAYMENT WORKSHEET

Total Amount Pledged

School Enrollment Costs

Total Amount Pledged & School Enrollment Costs


$
.00
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Payment Options

You have several options for how to make your payment. Use this section to work out the payment plan that works best for you. Use the choices below to explore the choices and costs. 

We ask that dues be paid in full by the end of Kehilla’s fiscal year – June 30, 2018
We prefer that you pay by check as we do not incur service charges. If you choose to use your credit card, we ask that you contribute an additional 2% of your total to help offset Kehilla’s credit card fee costs. Checks should be made out to Kehilla Community Synagogue and sent to 1300 Grand Ave. Piedmont, CA 94610.

PayPal is only available if you pay in full today.
CHECK PAYMENTS


Check Installments

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$
CREDIT CARD PAYMENT OPTIONS

Paying in Full? You will be using PayPal. Paying in Installments? You will be using Click & Pledge.

Payment In Full

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$

$
Typing your amount here confirms your commitment to make this payment. Your registration is not complete until you finish payment.
You have chosen to pay in Full with you credit card.  When you push submit you will be taken to a paypal page. You can pay with your credit card or your Paypal account if you have one.
Monthly Installment Payments


$

$
Credit Card Installment Directions
You have chosen the Credit Card Installment Plan.   When you submit this form you will be taken to the page where you will enter your credit card information.  
 
Please follow these directions when you get there:
  • Enter your installment amount ($) from section above 
  • Check the box for Recurring
  • Enter the number of installments (#) from section above
YOU WILL NOT BE ABLE TO RETURN TO THIS PAGE AFTER YOU SUBMIT.   
PLEASE MAKE A NOTE OF YOUR EXACT INSTALLMENT AMOUNT AND NUMBER OF INSTALLMENTS SO YOU CAN TRANSFER THE INFORMATION TO THE CREDIT CARD PAGE. 
  • It will look like this:
  • CNP Directions

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Emergency information
While your child is in our care, an accident, emergency or illness may occur that requires immediate medical attention without sufficient time to contact parent/guardians.  The California legislature has authorized consent in advance by parents or legal guardians for such treatment (Family Code Section 6910)




Who else is authorized to pick up your child? 




Emergency Contact 1



Please do not use the parent as an emergency contact.
Emergency Contact 2



Please do not use the parent as an emergency contact.
Authorization to Consent to Treatment of a Minor - I hereby authorize the Kehilla Community Synagogue/School representative to consent to any X-ray examination, anesthetic, medical, or surgical diagnosis or treatment or hospital care that is deemed advisable by, and is to be rendered under the supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act or to consent to any X-ray examination, anesthetic, medical, or surgical diagnosis or treatment or hospital care that is deemed advisable by, and is to be rendered under the supervision of any dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, hospital, or otherwise. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of said agent(s) to give specific consent to any and all such diagnosis, treatment and hospital care that such physician or dentist in the exercise of his/her best judgment may deem advisable. This authorization is given pursuant to the provisions of Family Code Section 6550-6552 of California and shall remain effective until revoked. It is understood that every effort will be made by Kehilla Community Synagogue/School to contact me before exercising this authorization. I hereby authorize Kehilla Community Synagogue/School to engage for my child(ren) at my expense any necessary emergency medical or dental care, until I can be informed and make further arrangements. I hereby incorporate by reference the "Authorization to Consent to Treatment of a Minor" as set forth above. This authorization will expire on June 30, 2018

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