Printed frommaayan-chai.org

ב"ה

Bat Mitzvah Club

BMC Registration Form

First Name*
Last Name*
English birth date*

Month Day Year
Hebrew birth date

Family's address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's name*
Father's name*
Mother's cell #*
Mother's e mail address*
Any conversions and/or adoptions in the family?

YesNo
Please explain
The 9 sessions' course fee is $ 360.

Payment

Credit Card Payment plan/financial aid

Postal / Zip Code

Country

I authorize the payment of $360*

Yes
Total

$0.00
Yes, I'd like to donate the cost of processing this transaction by adding 3%
Should be Empty:

This page uses TLS encryption to keep your data secure.

Programs