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Youth Programs Bar & Bat Mitzvah Club

Bar Mitzvah Club Registration

Bar Mitzvah Boy's Name*

First Name Last Name
Bar Mitzvah Boy's Jewish Name
Bar Mitzvah Boy's Birth Date*

Month Day Year
School He Attends*
Grade Starting Fall 2022*
Torah Reading Instruction*

Sepharad Ashkenaz
Mother's Name*

First Name Last Name
Mother's Jewish Name*
Mother's E-mail*
Mother's Phone Number*

Area Code Phone Number
Father's Name*

First Name Last Name
Father's Jewish Name*
Father's E-mail*
Father's Phone Number*

Area Code Phone Number

Address*

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

Marital Status*
Is there a Conversion in the family?*
Rabbi Who Performed the Conversion:

Payment $400*

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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