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*

Does your child have any medical, developmental or behavioral issue that we should know about? Please describe.
Additional notable Information
Parents' 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*
Mother's 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
Payment Information
Total

$0.00

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

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Parents' Information