Bat/Bar Mitzvah Club

Student Information
Full Name*
First Name Last Name
Full Hebrew Name*
First Name Last Name
Date of Birth*

Month Day Year
School Attending*
Grade Entering*
Hebrew Reading Proficiency

NoneSomewhatWell
Previous Jewish Education

YesNo
Where
Does your child have any allergies or other medical condition we should be aware of?*

YesNo
Please describe them and indicate special precautions or care needed.*
Trip Authorization*

I give permission for my child to participate on class trips throughout the school year
Parents Information
Marital Status*
Child lives with*
Is the natural mother of the child Jewish?*

YesNo
Have there been any conversions or adoptions in the family?*

YesNo
Please specify Rabbi and congregation
Parent 1*
First Name Last Name
Work Phone*
Cell Phone*
E-mail*

Address*

Address*

Primary Contact*

Parent 1Parent 2Both
Program
Our exclusive Bat Mitzvah club and Bar Mitzvah Division will be meeting monthly during the school year.

Total annual cost $600.
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Division:

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

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Student Information