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Bar Mitzvah Academy
First Name
Last Name
Hebrew Name
Example: David or דוד
Birth Date
Place of Birth
Do you know your child's Parsha?
Do you have a date set for the Bar-Mitzvah celebration?
Past Jewish studies lesson
Never
Village Hebrew
Private Tutor
Other
Home Address of child:
Email
Child lives with:
Cultural Background
Language used at home:
If there any conversion or adoption in your family?
Yes
No
If yes, please describe:
Payment Options
- select -
I will be paying full tuition by November 20, 2026
I will be paying tuition in 2 payments: November 20, 2026 & January 20, 2026
I will be paying tuition in 4 payments charged on the 20th of the month from November 20, 2026 to February 20, 2027
Visa / Mastercard / American / Express
Credit / Debit Card Information
Card Number
Name on card
Expiration (MM/YR)
Security Code
Billing Address
Billing Zip Code
Parent Information Father
Main Expectation:
Jewish Heritage
Bar Mitzvah Prep
Social Jewish Environment
All
Main email correspondence:
Mother
Father
Both
Primary mail correspondence:
Mother
Father
Both
Medical & Special Needs Details
Is your child taking permanent medication? If yes, please specify
Yes
No
Any known allergies(incl. reaction to medication)and any present medical conditions? Specify
No
Yes
Allergies
Nut Allergy
Asthma
Anaphylaxis
Other
Does your child require the use of an epi-pen?
Yes
No
Is your child gluten-free? Please list 2 snacks your child will enjoy:
Emergency Information
Emergency Contact
Relationship to Child
- select Relationship to Child -
Parent
Friend
Grandparent
Uncle
Aunt
Mother
Father
Sister
Stepfather
Home Telephone
Emergency Contact Cell Phone
Doctor's Name
Doctor's Phone
Doctor's Address
OTHER PERSON AUTHORIZED TO PICK-UP CHILD
Relationship to Child
Mobile Number
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