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ELC Release Form

45 Puddingstone Lane
Newton, MA 02459
617-527-0045 x110

* My child will arrive at the program:

Supervised walk
Unsupervised walk
Public/Private van
Program bus/van
Contract/van
Private trans. arranged by parent
Other

* My child will depart from the program:

Supervised walk
Unsupervised walk
Public/Private van
Program bus/van
Contract/van
Private trans. arranged by parent
Other

* Child's Name

* Parent Email

Person 1

Name

Relationship to Child

Address

Cell Phone Number

Person 2

Name

Relationship to Child

Address

Cell Phone Number

Person 3

Name

Relationship to Child

Address

Cell Phone Number

Person 4

Name

Relationship to Child

Address

Cell Phone Number

Person 5

Name

Relationship to Child

Address

Cell Phone Number

* By typing my name and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes.

I give my permission for my child to be released from the program to the people listed above. These names will be listed on our "Release To" sheet. Please note: Changes to this list must be done in writing.

* Date

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Checking Account

Name on the Account

Bank Name

Routing Number

Is usually located between the symbols on your check.

Account Number

Typically comes before the symbols. Its exact location and number of digits varies from bank to bank.

Confirm Account Number

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total:

For added Security please check the box below.

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Please contact Temple Beth Avodah at (617) 527-0045 if you have any questions or comments about the PAYQUIQ service or about payments.

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