ABOUT
PHOTO GALLERY REGISTER ONLINE

BAT MITZVAH CLUB REGISTRATION
We are currently accepting application forms for 2015-16. Please fill out ALL fields of this form. If you have any questions or concerns you'd like to discuss with us, please contact us.
*Please note that one registration form per applicant is needed.

APPLICANT INFORMATION
First & Last
Name
Hebrew Name
Age D.O.B.
School Grade Entering
Address City, State, Zip
City State Zip
Cell Phone Home Phone
Facebook Name Email

PARENT INFORMATION
Father's Name Religion
Occupation Business Name
Address City, State, Zip
City State Zip
Email Cell
Mother's Name Religion
Occupation Business Name
Address City, State, Zip
City State Zip
Email Cell

Marital Status of Parents:
Married Separated Divorced - How long?

EMERGENCY INFORMATION
In case of emergency, when neither parent can be reached, please list two contacts who will take responsibility for your child:
Emergency Contact 1 Relation to Child
Phone Business Phone
Emergency Contact 2 Relation to Child
Phone Business Phone

CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.

If parents cannot be reached and emergency medical advice is needed, permission is given to the BMC staff to phone my child’s doctor:
Doctor Phone
Address City
State, Zip
State Zip
Doctor's Hospital Affiliation

In case of emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary.
I Accept

PAYMENT PLAN

• There is an all inclusive fee of $200 for the full BMC year. Supplies: $50

I understand that by submitting this form I am committing to pay the above outlined fees.

Name:
Initials: Date: