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ב"ה

Youth Hebrew School

Youth Club Registration

Name of Girl Participant*
First NameLast Name
Birth Date*
MonthDayYear
Hebrew Birthday (if unknown, then time of day born)*
Full Hebrew Name
School*
Mother's name & Mother's Hebrew Name*
Mother's Cell Number*
Area CodePhone Number
Mother's E-mail*
Father's name & Hebrew name*
Father's Cell Number*
Area CodePhone Number
Father's E-mail*
Who in the family is Jewish*
MotherFatherBoth
Is either parent Jewish by choice? If yes, Which one?*
Marital Status of parents
MarriedDivorcedOther

Address*

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

What are you expecting your daughter to gain this year in Bat Club?*

Payment

Credit Card Pay by Check or Cash

Postal / Zip Code

Country

Bat Mitzvah Club Membership Dues
$175
Cteen Junior Club Membership Dues
$250
Total
$0.00
Should be Empty:

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