Bat Mitzvah Club

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Child's Information
Full English Name
Hebrew Name
Full Home Address
DOB
Time of Day Born
Jewish Birth Date (if known)
Current Grade
Current Age
Name of School
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?
Parent's Information
Father's Name
Home Phone
Cell Phone
Email
Mother's Name
Home Phone
Cell Phone
Email
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: $180.00/year (includes meetings, supplies, and materials.)
No one will be turned away for lack of funds. Payment Plans available.

Payment

Credit Card

/ Expiration MonthExpiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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