Bar/Bat Mitzvah Academy

Parent 1

First Name *

Last Name *

Hebrew Name *

Example: David or דוד

Gender *

Occupation *

Cell Phone Number *

Home Phone Number

Email *

Street Address *

City *

Postal Code *

State/Province *

Are you Jewish? *

Yes

Have there been any conversions in the family? *

Yes

Please Specify *

Synagogue Affiliation *

Marital Status of Child's Parents *

Name of Rabbi/Officiator *

Country of Birth *

Main Language/s *

Parent 2

First Name *

Last Name *

Hebrew Name *

Example: David or דוד

Gender *

Occupation *

Cell Phone Number *

Home Phone Number *

Email *

Share address of *

Check this box if Parent 2 shares the same address as Parent 1

Street Address *

City *

State/Province *

Postal Code *

Are you Jewish? *

Yes

Have there been any conversions in the family? *

Yes

Please Specify *

Synagogue Affiliation *

Country of Birth *

Main Language/s *

Child

First Name *

Last Name *

Hebrew Name *

Example: David or דוד

Gender *

Birth Date *

Month

Day

Year

Time of birth (required to calculate Jewish birthday) *

Child lives with *

Bar/Bat Mitzvah Academy

Date set for the Bar-Mitzvah celebration? *

Month

Day

Year

Main Expectation: *

Jewish Heritage

Bar Mitzvah Prep

Social Jewish Environment

All

Jewish Education Info

Past Jewish studies lesson *

Never

Village Hebrew

Private Tutor

Other

School *

Grade *

Prior Schools *

Other Child Info

Cultural Background *

Language used at home: *

Main email correspondence: *

Mother

Father

Both

Primary mail correspondence: *

Mother

Father

Both

Medical Information

Any known allergies(incl. reaction to medication)and any present medical conditions? *

Does your child require the use of an epi-pen? *

Yes

Is your child taking permanent medication *

Yes

Please list medications *

Is your child gluten-free? Please list 2 snacks your child will enjoy: *

Doctor Name *

Doctor Phone *

Doctor Address *

Emergency Contact

Name *

Relationship *

Home Phone *

Cell Phone *

Authorized Pick-Up

Name *

Relationship *

Cell Phone *

Address *

Bar & Bat Mitzvah Academy Registration Form

Village Synagogue