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Address

Child's Date of Birth

Month Day Year
at Hour Minutes
School Presently Attending
Schools Previously Attended
Parent Information
Mother's Name

First Name Last Name
Cell Phone

Area Code Phone Number
Is the child's biological mother born to a Jewish mother?

YesNo
Is the maternal grandmother born to a Jewish mother?

YesNo
Father's Name

First Name Last Name
Cell Phone

Area Code Phone Number
Is the father Jewish?

YesNo
Father is

KohenLeviYisrael
Are there any adoptions in the family?
Has anyone in your family converted?
If yes, who?
Emergency Contact & Medical Information
Full Name

First Name Last Name
Relationship to child
Phone Number

Area Code Phone Number
Ohip #
Please list any allergies or health concerns:
Child's hobbies, talents and interests:
I am able to host the Bat Mitzvah program in my home

YesNoMaybe, contact me for more information
Payment Information
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$400 for Paying Members$450 for Non-Members
Total

$0.00

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Bat Mitzvah Club