2021-22 Membership Renewal and School Form

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- **NEW** 2021-22 Membership Renewal and Religious School Registration
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Welcome!

By renewing your commitment to Temple Beth David, our community will continue to thrive. Your contributions make educational and social programming available for members of all ages, help maintain our physical building and grounds, and pay for staff salaries. Thank you for ensuring TBD's legacy remains vibrant and strong for this and future generations.

* Type of Renewal

Please Select OneMembership Renewal OnlyMembership Renewal and Religious SchoolIf you no longer wish to continue your membership with TBD, please select this option and enter your NAME and REASON you are not renewing in the space provided.

* Select your appropriate membership level

Please Select OneTwo Adult FamilyOne Adult FamilyOne Adult MembershipFriends & Family Out-of-State Membership (for members who live full-time outside of CT)Dual Synagogue Membership (for members active in more than one synagogue)Active Duty Membership (Must provide valid military ID)

* Please enter the name, address and telephone number of other synagogue of which you are a member.

Regardless of your membership level indicated above, please make a selection below to demonstrate the strongest financial commitment you can make to Temple Beth David. If you are able to participate at the Honor Circle level, please know your generosity will help ensure no family is turned away from TBD's Jewish community. We are especially grateful to our Honor Circle members for allowing TBD to continue providing and sustaining Jewish life in our community.

* Financial Commitment

Please Select OneHONOR CIRCLE Tree of Life Honor Society - $18,000HONOR CIRCLE Call to Action Honor Society - $10,000HONOR CIRCLE Hand of Miriam Honor Society - $7200HONOR CIRCLE Rabbi's Honor Society - $5400HONOR CIRCLE Double Chai Honor Society - $3600HONOR CIRCLE President's Honor Society - $3115HONOR CIRCLE Chai Membership - $2590Two Adult Family - $2190One Adult Family - $1775One Adult Membership -$980Friends and Family Out-of-State Membership - $650Dual Synagogue Membership - $575Active Duty Membership - $0TBD is committed to ensuring our doors are open to all, regardless of financial circumstances. To make a membership commitment at another level, select this option and our Financial Secretary will be happy to reach out to you.

BUILDING MAINTENANCE FEE

* I understand all households are assessed a $150 annual building maintenance fee.

I understand all households are assessed a $150 annual building maintenance fee.

* How many Adults are part of this Membership Renewal?

Please Select OneOne AdultTwo Adults

PERSONAL INFORMATION

Adult 1 Information

* First Name

Middle Name

* Last Name

* Phone Number

* Email

Birth date

Occupation

Adult 1 TBD Involvement

We encourage active participation of all our members in temple life. Please indicate below any activities or committees of interest and a committee chairperson or board member will contact you.

Adult Education – Develops opportunities for all members to be lifelong Jewish learners. This is achieved through Torah study sessions, book groups, Hebrew classes, guest lecturers, and workshops to deepen understanding of ritual practice.Brotherhood – TBD Brotherhood welcomes men of all ages to join in social interaction and performing mitzvot in support of the congregation.Budget and Finance – Submits an annual budget to the board and helps to oversee the finances of the congregation.Building and Grounds – Coordinates the upkeep of TBD’s building and property.Caring Community – Helps all congregants feel that they are part of a community by enabling them to celebrate and acknowledge happy occasions and to offer support during times of sadness, illness, or stress.Communications (Publicity, Web Page, Temple Bulletin) – Ensures that TBD and the outside community are informed of upcoming events and opportunities to become a part of our congregation.Education (Religious School) – Works cooperatively with our director of education on special events for our religious school by developing school policies, coordinating parent volunteers, and supporting teachers and staff.Fund Raising – Works to raise funds that allow TBD to advance our mission.Membership Committee – Focuses on the recruitment of new members and the retention and engagement of current members.Mitzvah Garden – Beginning in 2011, TBD’s Mitzvah Garden has been led by a tireless group of green thumb volunteers whose efforts have provided over 2,000 pounds of fresh vegetables annually for local food pantries.Ritual Committee – In collaboration with our rabbi, works to enhance spiritual growth of our congregation.Sisterhood – Embraces all women members of TBD and supports the temple’s mission, the Jewish community, and the local community through fundraising and social events.Social Action Committee – Helps TBD to fulfill one of the tenets of our mission statement: working toward Tikkun Olam, "healing of the world” through projects such as food drives and Mitzvah Day.Social Committee – Plans enjoyable events that foster a sense of community at TBD.TBD Tribe – A social group geared toward the temple’s Gen X, Gen Y, and Millennial crowd, TBD Tribe is for members looking to socialize, meet new people, or just have fun with their Jewish community.TBD Youth – Engages our teens in temple life, whether as part of our school community serving as both teachers and teacher’s aides, working with our social action committee on community wide projects, or getting to know each other through fun, social

Please indicate any skills, talents, or experience which you may wish to share with the temple (e.g. accounting, computers, writing, public relations, Hebrew or Judaic knowledge, Torah chanting, music):

Adult 2 Information

* First Name

Middle Name

* Last Name

* Phone Number

* Email

Date of Birth

Occupation

Adult 2 TBD Involvement

We encourage active participation of all our members in temple life. Please indicate below any activities or committees of interest and a committee chairperson or board member will contact you.

* How many children will be included in your membership renewal?

Please Select OneNoneOne ChildTwo ChildrenThree ChildrenFour Children

Please include the names of all your children under the age of 25 as they are included in your membership. Children 26 and older must apply for membership on their own.

Child 1

* First Name

Middle Name

* Last Name

* Date of Birth

Child 2

* First Name

Middle Name

* Last Name

* Date of Birth

Child 3

* First Name

Middle Name

* Last Name

* Date of Birth

Child 4

* First Name

Middle Name

* Last Name

* Date of Birth

RELIGIOUS SCHOOL ENROLLMENT INFORMATION

How many children are being enrolled in Temple Beth David's Religious School Program?

Please Select OneOne StudentTwo StudentsThree StudentsFour Students

Religious School Registration

2021-22 School Tuition and Fees:

Pre-K/K - $470
1st Grade - $555
2nd Grade - $615
3rd Grade - $740
4th Grade - $820
5th Grade - $850 + B'nai Mitzvah Assessment of $150
6th Grade - $890 + B'nai Mitzvah Assessment of $250
7th Grade - $1065 + B'nai Mitzvah Assessment of $250

* Name of Student 1

* Name of Student 2

* Name of Student 3

* Name of Student 4

Hebrew Name of Student 1

Hebrew Name of Student 2

Hebrew Name of Student 3

Hebrew Name of Student 4

Name of secular school Student 1 is entering in the fall

Name of secular school Student 2 is entering in the fall

Name of secular school Student 3 is entering in the fall

Name of secular school Student 4 is entering in the fall

Secular school grade entering in the fall - Student 1

Secular school grade entering in the fall - Student 2

Secular school grade entering in the fall - Student 3

Secular school grade entering in the fall - Student 4

* Religious School Grade Entering in the Fall - Student 1

Please Select OnePre-K/KGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7

* Grade Entering in the Fall - Student 2

Please Select OnePre-K/KGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7

* Grade Entering in the Fall - Student 3

Please Select OnePre-K/KGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7

* Grade Entering in the Fall - Student 4

Please Select OnePre-K/KGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7

* I grant permission for photos of my child(ren) to be used in promotional material for TBD programs and for use on the Temple website and social media.

Please Select OneYesNo

EDUCATIONAL CONSIDERATIONS

In the text box(es) below, please note if your child(ren) receive(s) any education services, such as IEP, Adaptive Equipment, Special Education, Outside Tutoring, Physical / Occupational Therapy, Behavioral Resource, Gifted/Talented, etc.

Student 1

Student 2

Student 3

Student 4

Student 1 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 2 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 3 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 4 - What are your child's strengths? (Highlight all areas in which your child does well, including educational and social.)

Student 1 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

Student 2 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

Student 3 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

Student 4 - What are your child's greatest challenges? (List areas in which your child has the greatest difficulties.

DIAGNOSES OR ASSESSMENTS

In the text box(es) below, please note if your child(ren) is/are diagnosed as having, or is being assessed for any of the following: ADHD, Anxiety, Autism Spectrum Disorder, Conduct/Oppositional Disorder, Developmental/Cognitive Delay, Depression, Emotional/Behavioral Disorder, Hearing Disorder, Learning Disability, Obsessive Compulsive Disorder (OCD), Speech/Language Disability, Physical Disability, Cerebral Palsy, Tourette Syndrome, Visual Impairment, Other.

Student 1

Student 2

Student 3

Student 4

MEDICAL INFORMATION

* In case of medical emergency, if parents or emergency contact cannot be reached, Religious School staff has my permission to seek emergency medical care for my child.

Please Select OneYesNo

Pediatrician's name and phone number

Insurance Company

Insurance Policy Number

Please list any serious allergies Student 1 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any serious allergies Student 2 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any serious allergies Student 3 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any serious allergies Student 4 has including food allergies, bee stings, etc. and what action must be taken in the event of exposure to an allergen.

Please list any medications Student 1 is taking.

Please list any medications Student 2 is taking.

Please list any medications Student 3 is taking.

Please list any medications Student 4 is taking.

* Who is allowed to pick up your child(ren) from school?

Please enter one or more names of people you authorize to pick up your child(ren) after school.

EMERGENCY CONTACT INFORMATION

Please list two people who we may contact in the event we are unable to reach a parent in an emergency.

* Emergency Contact 1
First Name

* Emergency Contact 1
Last Name

* Emergency Contact 1 Relationship

e.g. grandparent, aunt, family friend, etc.

* Emergency Contact 1 Phone

* Emergency Contact 2
First Name

* Emergency Contact 2 Last Name

* Emergency Contact 2 Relationship

e.g. grandparent, aunt, family friend, etc.

* Emergency Contact 2 Phone

ADDITIONAL DONATION TO TEMPLE BETH DAVID

Inspiring worship, engaging study, meaningful social action; all are made possible by your generosity. While membership contributions sustain our community at the basic level, your additional donations of the heart have allowed us to do so much more. If you'd like to make an additional gift to support a specific cause at TBD, please enter the amount in the appropriate box below.

Education Fund

Endowment Fund

General Fund

Mitzvah Garden Fund

Rabbi's Discretionary Fund

Social Fund

Youth Engagement Fund

TOTAL:

Includes Membership, Building Maintenance Fee, Sisterhood, donations, and school registration fees.

MEMBERSHIP SUMMARY

* I hereby commit to renewing my membership at Temple Beth David and agree to fulfill my financial obligations as indicated above.

I hereby commit to renewing my membership at Temple Beth David and agree to fulfill my financial obligations as indicated above.

* First and Last Name

* Date

ADMINISTRATION

On the next page you will be presented with payment options.

You may make your payment by ACH/eCheck, credit card, or choose to have it billed to your account so that you may make other arrangements, such as paying by check.

If you choose to pay by ACH/eCheck or credit card, you may also specify if you wish to pay in full via a single payment, or via 2-10 monthly installments, right on the payment page. If you choose to pay now via a single payment, your account will be charged on 07/01/2021 or the date you made your payment, whichever is later.

IMPORTANT NOTE: We strongly encourage you to select either ACH/eCheck or a credit card for your payments. By using one of these methods it improves the temple's ability to serve our members and reduces manual input.

TO PAY BY CHECK, PLEASE READ BELOW:
If you wish to pay using an alternate method (e.g. mailing in a check), on the next page please select Pay this amount [Once Now], then select the default payment method Bill To My Account. (You must be logged in to see this option so the system knows which account to bill.) Even though you are required to select [Once Now], you can submit payments as you wish (monthly, quarterly, etc.).

Please click the 'Save and Continue' button below.

Wed, January 19 2022 17 Shevat 5782