BAR MITZVAH CLUB REGISTRATION
We are currently accepting application forms for 2016-17 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 Seperated 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 a suggested fee of $180 for the full BMC year. Supplies: $50.

•Sponsor a Bar Mitzvah Club event in honor of a loved one. $250. For more info please call Rabbi Winner: 718-687-7844
I understand that by submitting this form I am committing to pay the above outlined fees.
Name:
Initials: Date: