Bar/Bat Mitzvah registration Form

Bat Mitzvah Girl's Information
Full Name*

First Name Last Name
Hebrew name (if known)*
Birth Date*

Month Day Year
Time of birth (if recalled). This information helps us calculate the exact Hebrew Birthday.

Hour Minutes

Address*

Address*

Address*

Mobile Phone
E-mail*
Jewish status*

from birth converted
marital status*
If any conversions in the family, please provide conversion details*
Synagogue affiliation (if any)
Emergency Information
Emergency Contact*

First Name Last Name
Relationship to child*
Emergency phone or mobile*
GP name
GP number
Declaration of Parent or Guardian
I hereby authorise Chabad Carnegie leaders and staff to obtain any medical care necessary for my child. I understand that in the case of emergency of any significant illness or injury, attempt will be made to contact myself when practical. I agree to pay for any cost that may occur as a result of the injury/illness. I acknowledge my child may be participate in activities within and outside the Chabad grounds. I authorise my child to participate in these activities. I hereby authorise Chabad Carnegie to photograph my child and to use the photographs at their discretion.
I agree to the above
Date

Month Day Year
Declaration Name*

First Name Last Name
In order to secure your place, a $100 non-refundable deposit is necessary.

I understand that the Application fee of $100 is the first installment of payment and and is on the basis of completing the full year program. I authorise Bar/Bat-Mitzvah club (Chabad Carnegie) to charge my credit card accordingly. I also understand that the Application fee of $100 is non-refundable.

Payment

Credit Card

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Bat Mitzvah Girl's Information