Please enable JavaScript in your browser to complete this form.June 1, 2022 to May 31, 2023 11301 W. Broward Boulevard, Plantation, FL 33325 954-472-3600/ Fax 954-472-3622 ramatshalom@ramatshalom.orgHousehold InformationFamily Name: *Home Phone: *Address: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAdult 1 Name: *Adult 1 Cell Phone: *Adult 1 Email: *Adult 2 Name:Adult 2 Cell Phone:Adult 2 Email:Does Ramat Shalom have permission to share your contact information with the congregation? *YesNoName, Grade, School, and Email for ALL CHILDREN (including college and university) as of August 2022Child 1 Name:Child 1 Identified Gender:Child 1 Grade:Child 1 School:Child 1 Email:Child 2 Name:Child 2 Identified Gender:Child 2 Grade:Child 2 School:Child 2 Email:Child 3 Name:Child 3 Identified Gender:Child 3 Grade:Child 3 School:Child 3 Email:Please Refer To The Fee Schedule To Complete The Following:Congregational FeesOpportunities to Give!Congregational Fees (Section A on Fee Sheet):Torah School Assistance Fund:Registration Fee $100 (waived before 6/15):Gift of the Heart Scholarship Fund:Torah School/iServe Fees (Section B on Fee Sheet):Sam & Laura Hoffman Scholarship Fund:Torah School Registration Fee $100 (waived before 6/15):Burning the Mortgage Fund:Additional FeesCongregational Fees SUB-TOTAL : Security: (Required per household)$200.00Additional Fees SUB-TOTAL:Kochavim (Youth Choir):$80/childOpportunities to Give SUB-TOTAL:TOTAL:*Separate application for Torah School and youth programs MUST be completed for each child.Payment OptionsPay in FullPay in 4 Installments, $12/payment installment fee (payments due: 6/1, 8/1, 10/1, 12/1)Pay in 10 Installments, $12/payment installment fee (payments due monthly beginning on 6/1)NOTE: If you are paying in installments, please contact our office. Whenever possible, we appreciate your payment by check or cash. All credit card transactions will be assessed a 3% convenience fee.Payment InformationCheck #:Check Amount Enclosed:Am. Express, Visa, MasterCard, Discover Account #:Expiration Date:Name (as it appears on credit card):Credit Card Billing Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeThe congregational year for Ramat Shalom begins June 1st, 2022. I understand that membership dues are payable annually and are not transferable or refundable. In the event that I am unable to meet any of these payments or require a change in my payment arrangement, it is my obligation and responsibility to notify the Director of Administration to avoid losing my membership-in-good-standing and the attendant rights.Electronic Signature: *Date: *By clicking Submit, I authorize Ramat Shalom to automatically charge the above credit card according to the method of payment specified above. *Click to acceptSubmit
