Bat Mitzvah Registration

Parent Name*

First Name Last Name

Address*

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

Child Information

Full Name*

Full Name Last Name

Hebrew Name*

First Name Second Name

Child's E-mail*

Child's Cell*

Area Code Phone Number

Date of Birth*

Month Day Year

Time of Birth Required to calculate Hebrew date

Hour Minutes

Child* Please Choose One

Biological Mother* Please Choose One

Biological Maternal Grandmother* Please Choose One

Father* Please Choose One

Please note if child has any learning disabilities or difficulties*

Parent Information

Mother

Name*

First Name Last Name

Cell*

E-mail*

Father

Name*

First Name Last Name

Cell*

E-mail*

Service

Desired Month* First Choice

Month Day Year

Desired Month* Second Choice

Month Day Year

Estimated # of Guests in Attendance

Parental Consent

Consent*

I understand that it is my responsibility to oversee my child’s progress, ensure that they thoroughly review the material learned 5 days each week, and to personally study with them if necessary in order to successfully meet the goals of Bat Mitzvah preparation.I agree to make payment of $1,800 to Chabad of NWBC for weekly 30 minute Bat Mitzvah lessons according to the schedule of Bat Mitzvah lessons.I agree to make a minimum donation of $1,600 to Chabad of NWBC for the Bat Mitzvah. This includes meetings with parents, rehearsal, use of facility for service ONLY, and conducting of the service by Rabbi or Mimi Kaplan as arranged.I understand that if desired, Coffee, cake and fruit may be served for a charge of $8 per person and $250 for set-up and linen.

Payment Details

Payment Plan*

I will pay $3,400 at this time with the credit card below.I agree to pay $3,400 divided in four payments charged to the credit card below.

Donation This is in ADDITION to the required fees listed above

Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment* Card will be processed manually based on your selection above

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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