Registration for Bar and Bat Mitzvah Clubs

If any question is not applicable, please write N/A

Father's Name*

First NameLast Name

Father's Cell*

Area CodePhone Number

Father's Email*

Mother's Name*

First NameLast Name

Mother's Cell*

Area CodePhone Number

Mother's Email*

Do Parents Live Together?*

YesNo

Address*

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

Father's Address*

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

Mother's Address*

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

Are there any conversions or adoptions in the family?

Mother*

YesNo

Maternal Grandmother*

YesNo

Maternal Grandfather*

YesNo

Father*

YesNo

Paternal Grandmother*

YesNo

Paternal Grandfather*

YesNo

Please provide further details about conversions and/or adoptions in the family.

Are the biological parents of the child/ren Jewish?

Father*

YesNo

Mother*

YesNo

Full Name*

First NameLast Name

Please select the program this child will be joining*

Bar Mitzvah ClubBat Mitzvah Club

Hebrew Name

Birth Date*

MonthDayYear

Child's E-mail*

Child's Cell #*

Area CodePhone Number

Preferred Date for the Bar Mitzvah Ceremony

MonthDayYear

Participants in the Bar & Bat Mitzvah Clubs must be attending a Jewish day school or religious school for this academic year. Which school will your child be attending?*

Is this child enrolled in the Chabad Hebrew School for the 2021 - 2022 school year?*

YesNo

Please list the names and ages of other children living at home

Total Due

$0.00

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

I would like to receive news and updates by email

Registration for Bar and Bat Mitzvah Clubs

Parents Information

Child Information

Payment