PAYQUIQ ONLINE :: The Faster Smarter Way to Pay

* I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize Temple Beth Avodah to transport my child to the nearest medical facility and secure necessary medical treatment for my child.

Yes, I understand the above statement.

Medical Emergency Contacts

Please note: ALL fields are required. Please list both parents, if applicable, and at least one other person. Please type in "N/A" for fields not used.

* Medical Emergency Contact 1

* Address

* City, State, Zip

* Relationship to Child

* Home Phone Number

* Cell Phone Number

* Do you give permission for your child to be released to this person?

* Medical Emergency Contact 2

* Address

* City, State, Zip

* Relationship to Child

* Home Phone Number

* Cell Phone Number

* Do you give permission for your child to be released to this person?

* Medical Emergency Contact 3

* Address

* City, State, Zip

* Relationship to Child

* Home Phone Number

* Cell Phone Number

* Do you give permission for your child to be released to this person?

* Medical Emergency Contact 4

* Address

* City, State, Zip

* Relationship to Child

* Home Phone Number

* Cell Phone Number

* Do you give permission for your child to be released to this person?

Health Insurance Information

* Health Insurance Coverage

* Policy Number

* Parent 1 Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

* Parent 2 Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Signature & Date

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

* Date

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

ELC First Aid and Emergency Medical Care Consent Form

Account Details

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

Payment Information

Credit Card

Checking Account

For added Security please check the box below.

ELC First Aid and Emergency Medical Care Consent Form

Account Details

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

Payment Information

Credit Card

Checking Account

For added Security please check the box below.

Image Preview