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Youth Bat Mitzvah Club

BMC Registration

Bat Mitzvah Club Application
Bat Mitzvah Girl Name*

First Name Last Name
Bat Mitzvah Girl Hebrew Birthday*
Bat Mitzvah Girl English Birthday*

Month Day Year
Parent's Name:*

First Name Last Name
Parent E-mail:*
Parent's Phone:*

Area Code Phone Number

Home Address* (to drop off supplies)

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

Name of School*
Best weekday

Monday Tuesday Wednesday Thursday
Preferred times

4:00 4:30 5:00 5:30
Is there a day or time that can not work and if yes when?
Registration fee for the year*

$360

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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