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Bat Mitzvah Club

ב"ה

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Parent's Information
Father's Name
First Name Last Name
Father's Email
Father's Phone Number
Mother's Name
First Name Last Name
Mother's Email
Mother's Phone Number

Address

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

Best way to contact my child in between meetings (please specify if child has email and/or cell phone)
What are some things that you and/or your child hope to gain, by joining the Bat Mitzvah Club?
Child's Information
Full English Name
First Name Last Name
Hebrew Name
Child's E-mail
Child's Phone Number

Home Address

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

Date of Birth

Month Day Year
Jewish Birth Date (if known)
Current Grade
Name of School
Girl's biological mother is

Jewish from birthNot JewishConverted
Maternal grandmother is

Jewish from birthNot JewishConverted
Emergency Information
Does your child have any allergies and/or medical conditions we should be aware of?
Emergency Contact Person and number (in case either parent can’t be reached)
Payment Information
Fee: $360/year, and $100/supplies and materials fee.
Pay in full now, $460Divide payment in two: $230 in January and $230 in May
Total

$0.00

Payment

Credit Card Check

Postal / Zip Code

Country

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