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Bar/Bat Mitzvah Registration Form

I would like to register for:*

Bar Mitzvah Club - Jan 12, 19, 26, Feb 2, 9, 16, 23, Mar 9- $199Bat Mitzvah Club - Jan 19, 26, Feb 2, 9, 16, 23 - $179
Child's Name*
First Name Last Name
Hebrew Name*
First Name Last Name
Birth Date*

Month Day Year
Previous Jewish Education*
School*
Grade*

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Father's Name*
First Name Last Name
Father's Phone Number*
Father's E-mail
Mother's Name*
First Name Last Name
Mother's Phone Number*
Mother's E-mail*
Are the natural father and mother of the child Jewish?*

YesNo
If not, please explain:
Have there been any conversions in the family?*

YesNo
If yes, please explain:
Emergency Contact*
First Name Last Name
Phone Number*
Relationship to Child*
Total

$0.00

Payment

Credit Card Check or Cash

Postal / Zip Code

Country

Should be Empty:

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