Bat Mitzvah Club Form

Registration Form
Child's Name*

First Name Last Name
Child's Hebrew Name*
Birth Date*

Month Day Year
Is your Child part of Chai Hebrew?*

YesNo
Parents
Marital Status*
Is the natural mother of the child Jewish*
Has there been any conversion in the family*
Was the conversion by an Orthodox Beth Din**
If yes, please specify Rabbi and Congregation Before registering, please ensure that your conversion is recognized by The Rabbinical Council of America
Parent 1
Full Name*

First Name Last Name
E-mail*
Phone Number*
Hebrew Name*
Born Jewish*
Gender*
Occupation*

Address*

Parent 2
Full Name*

First Name Last Name
E-mail*
Phone Number*
Hebrew Name*
Born Jewish?*
Gender*
Occupation*
Any additional notable information about the family
Primary Correspondence should be with*
Preferred method of communication*
Emergency Information
Emergency Contact*

First Name Last Name
Phone Number*
Relationship to Child*
Does your child take any medications or have any allergies or other medical conditions we should be aware of? If yes, please describe. if no, please write noIf yes, please describe. if no, please write no
I hereby give permission for my child(ren) to attend all field trips and outings*

Yes
I hereby give permission for my child(ren) to be photographed during BMC activities, and for the photographs to be published on BMC website and media.*

Yes
Pay in Full

$350
Help sponsor a child

$350
Payment Plan - I will speak to Shaina.

Check here
Additional Donation

$50.00$75.00$100.00$180.00$500.00$1000.00$1800.00
Total

$0.00

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

City

State / Province

Postal / Zip Code

Country

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Programs

Registration Form