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Children & Teens Cteen JR

Youth Clubs Reg Form

Youth Clubs Registration Form
Date for Bar / Bat Mitzvah Reception If applicable

Month Day Year
1. The Child
Child Name*
First Name Last Name
Hebrew Name
Date of Birth*

Month Day Year
Time of Birth*
Hour Minutes
Entering Grade*
Name of School*
2. The Parents
Father's Name*
First Name Last Name
Father's Hebrew Name
Father is a* Kohen, Levi, Israelite or Do Not Know?
Is Father's Mother Jewish?*
Father's Cell*

Area Code Phone Number
Father's Email
Mother's Maiden Name*
First Name Last Name
Mother's Hebrew Name
Is Mother's Mother Jewish?*
Mother's Cell*

Area Code Phone Number
Mother's Email

Home Address*

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

Are Parents Currently Married?*
Any Adoptions in the Family?*
If yes Please Explain
Any Conversions in the Family?*
If yes Please Explain
Sign In Your Name* I certify that the statements and information contained in this document is true, accurate and complete.
3. Club Membership
Choose Club*

Bat Mitzvah Club (BMC)Bar Mitzvah eXperience (BMX)Cteen JR
Annual club membership*

$350

Payment*

Credit Card Other

Postal / Zip Code

Country

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