בס"ד Bar Mitzvah Club REGISTRATION FORM 2021 - 5782 Please carefully complete this form, then click submit. This page uses 128 bit SSL encryption to keep your data secure. Member's Information Family Name: English Name: Hebrew Name: Date of Birth: -- Month -- Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec -- Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- Year -- 2000 2001 2002 2003 2004 2005 2006 2007 2008 Jewish Date of Birth online date calculator School: Grade: Fully vaccinated other Address: City: Postal Code: Member's E-mail: Parent's Information Member is in care of: -- Select -- Both Parents details in comment section below Father's English Name: Father's Hebrew Name: Father is: -- Select -- Jewish by Birth Other, use comment section below Father's E-Mail: Mother's English Name: Mother's Hebrew Name: Mother is: -- Select -- Jewish by birth Other, use comment section.below Mother's E-Mail: Bar Mitzvah Celebration If you have plans for the celebration your Bar Mitzvah, please BREIFLY describe them. If you do not, we would be happy to discuss various options with you. Payment Information (cost is $100) Preferred Payment Method: -- Select-- Visa Master Card Cash / Cheque Name on Credit Card: Credit Card Number: Code: Expiry Date: -- Month -- Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec -- Year -- 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Other Please enter any comments you have below: This page uses 128 bit SSL encryption to keep your data secure.