Bat Mitzvah Club Registration

Family Name
First Name
Date of Birth
Night/Day
Hebrew Name
Address
Postal Code
Telephone (home)
School attending
Mother's Name
Mother's Hebrew Name
Mother's cell #
Mother's email
Business name and telephone
Father's Name
Father's Hebrew Name
Father's cell #
Father's email
Business name and telephone
Has your daughter had any other Hebrew education
Is there any medical problem, disability, and/ or allergy
Parent Status
Payment method ($69 registration fee)
Name on card
Card Number
Expiration date (mm/yy)

I hereby certify that all information given above is true and correct and that the Bat Mitzvah girl is Jewish by birth or by conversion by an Orthodox Rabbi

Parent's Initials