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Pre Bar Mitzvah Club

Child's Full Name*

First Name Last Name
Child's Birth Date*

Month Day Year
What time of day was the child born?*
Child Hebrew Bday, if known
School Child Attends*
Mother's Full Name*

First Name Last Name
Mother's Hebrew Name*

First Name Last Name
Mother's Phone Number*

Area Code Phone Number
Mother's E-mail*
Father's Full Name*

First Name Last Name
Father's Hebrew Name*

First Name Last Name
Father's Phone Number*

Area Code Phone Number
Father's E-mail*
Registration Fee*

$69
Total

$69.00

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

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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