Bat Mitzvah Club

For more information and any questions, please reach out to Mushkie at 727-430-0473.

Child's Name*

First Name Last Name

Hebrew Name*

Birth Date*

Month Day Year

To determine her Bat Mitzvah date, what time of day was your daughter born?

Hour Minutes

Grade Entering*

Address*

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

Does your child have any medical, developmental or behavioral issue that we should know about? Please describe.

Additional notable Information

Father's Name*

First Name Last Name

Father's E-mail*

I would like to receive news and updates by email

Father's Phone Number

Father's Hebrew Name

Mother's Name*

First Name Last Name

Mother's E-mail*

Mothers Phone Number*

Mother's Hebrew Name*

Emergency Contact Name*

First Name Last Name

Emergency Contact Phone Number*

Were there any conversions or adaptions in the family (parents, grandparents, children etc)?*

YesNo

If yes, please specify who converted.

Was the child born Jewish?*

YesNo

Does your child have any allergies?*

YesNo

If yes, please specify allergies.

*

I allow my child to be photographed while participating in the BMC activities and these pictures may be used for marketing purposes.I give permission for my child to attend any field trips and outings that may take place during Bat Mitzvah Club.

Bat Mitzvah Club Sessions*

$360

Bat Mitzvah Celebration

$500

Total

$360.00

Payment

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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

Parents' Information

Payment Information