BAT MITZVAH CLUB REGISTRATION
 This is a secure form.
(Uses 128 Bit SSL Encryption to protect credit card numbers.) 

Child's Information 

English Name

Hebrew Name 
Date of Birth 
Entering Grade
Name of School

Are the natural mother and father of the child Jewish?
Yes   No 
If not please explain

Family Information

Father's Name
Email Address

Address:

City :
State:  Zip:
Telephone numbers: Home:
Work:
Cell:



Mother's Name
Email Address
Address: (if different)
City:  (if different)
State:  Zip:
Telephone numbers: Home:
Work:
Cell:




 Emergency Contact

Name
Relationship
Telephone numbers: Home
Work
Cell 




Allergy Information

 Please provide any allergy information we shoud know about.

 

 

Schedule of fees:

 

$180 (Includes all sessions, supplies and snacks.)

 

Terms of Payment:

 

Please invoice me
Please charge my credit card

 

Credit Card Information:

 

Name on Card
CC Number
Expiration Date

 

In the event of an emergency, Chabad Lubavitch of Alexandria-Arlington has my permission to arrange for any necessary first aid or care by a licensed physician for my child while he/she is attending the program.

I have completed the registration form and have mailed the registration fee - if applicable - (see terms of agreement) to 3213 Duke Street #630, Alexandria, VA 22314as well as the appropriate payment for my child(ren) to attend the Chabad Lubavitch of Alexandria-Arlington Bat Mitzvah Club.

Signature of parent or legal guardian.