Registration for Bar and Bat Mitzvah Clubs

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

Father's Name*

First Name Last Name

Father's Cell*

Area Code Phone Number

Father's Email*

Mother's Name*

First Name Last Name

Mother's Cell*

Area Code Phone Number

Mother's Email*

Do Parents Live Together?*

Yes No

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*

Yes No

Maternal Grandmother*

Yes No

Maternal Grandfather*

Yes No

Father*

Yes No

Paternal Grandmother*

Yes No

Paternal Grandfather*

Yes No

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

Are the biological parents of the child/ren Jewish?

Father*

Yes No

Mother*

Yes No

Full Name*

First Name Last Name

Please select the program this child will be joining*

Bar Mitzvah Club Bat Mitzvah Club

Hebrew Name

Birth Date*

Month Day Year

Child's E-mail*

Child's Cell #*

Area Code Phone Number

Preferred Date for the Bar Mitzvah Ceremony

Month Day Year

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 2022 - 2023 school year?*

Yes No

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

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Registration for Bar and Bat Mitzvah Clubs

Parents Information

Child Information

Payment