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Youth Bar/Bat Mitzvah Club and Beyond

Bar Mitzvah Club Registration

Bar Mitzvah Club Registration
Parent Information
Mother's Name
First NameLast Name
Mother's Maiden Name

Address

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

Home Phone Number
Area CodePhone Number
Cell Phone Number
Area CodePhone Number
E-mail
Boy's biological mother is
Jewish from birthNot JewishConverted
Maternal grandmother is
Jewish from birthNot JewishConverted
Father's Name
First NameLast Name

Address (if different)

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

Phone Number
Area CodePhone Number
E-mail
Boy's father is
Jewish from birthNot JewishConverted
Student Information
Full Name
First NameLast Name
Hebrew Name
Birth Date
MonthDayYear
Time (Approx)
HourMinutes
Sibling Information
Sibling 1
First NameLast Name
Hebrew Name
Birth Date
MonthDayYear
Sibling 2
First NameLast Name
Hebrew Name
Birth Date
MonthDayYear
Sibling 3
First NameLast Name
Hebrew Name
Birth Date
MonthDayYear
Emergency Contact and Medical Information
Contact 1
First NameLast Name
Phone Number
Area CodePhone Number
Relationship
Contact 2
First NameLast Name
Phone Number
Area CodePhone Number
Relationship
Physician Name
Phone Number
Area CodePhone Number

Address

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

Does your child have any allergies?
YesNo
If yes, please specify
Any medical info BarMC leader should know about?
YesNo
If yes, please specify.
Total
$0.00
Please charge
Full amount of $900$180 payment every month for 5 months. (First payment is charged upon registration)

Payment

Credit Card

Credit Card Type
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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